Pat Sidley dissects the profound — and controversial – – changes proposed for South Africa’s health services
‘A caring health service” is the Department of Health’s=20 slogan describing its work. And it’s been a gruelling=20 five months for its committee charged with starting the=20
The Committee of Inquiry into a National Health=20 Insurance System has reported its findings, made=20 several recommendations (and ducked others) after=20 hundreds of hours of oral submissions and thousands of=20 pages of written submissions; it has taxed the best=20 brains in the country — which were carefully selected=20 around gender and race isues — as well as significant=20 talent from three other countries.
The report promises to change profoundly the face of=20 health care in the country — to a service which=20 provides cheap (and sometimes free) basic care for the=20 majority of people who have not had it before.
Anybody who is sick will be treated at a nearby primary=20 health care centre. It may be a clinic, a small=20 practice around a primary health care nurse, or in some=20 cases, a hospital. In many areas, the most important=20 person who will make the initial examination and=20 diagnosis will be a nurse — who will have received a=20 special training.
People getting this service will have to be “permanent=20 residents” — a potentially explosive issue, already=20 causing a problem to the medical aid groups who will be=20 shouldering the bulk of the costs.
Prospective patients will have to be registered in=20 their areas at a district health authority. This will=20 require a larger effort than Home Affairs is making to=20 register voters.
The professional staff at the primary health care=20 facility will also have to be registered and will have=20 some type of accreditation with the authority — which=20 will ensure that they get paid for the work they are=20
The person who runs the facility may prescribe=20 medicines from a list laid down by the government. This=20 list will specify which drugs can be used, how they=20 should be used and who should prescribe them. The=20 patient will be charged a small fee for the drugs –=20 but if he or she cannot pay, the drugs will be=20 dispensed anyway. The rest of the treatment will be=20
If the patient is particularly ill, or if the complaint=20 falls outside the scope of the medical professional on=20 duty, she will be referred by that person to a larger=20 hospital for treatment. But if the patient goes to the=20 hospital without going first to primary health care=20 centre — providing there is one and it is not an=20 emergency — the patient will end up being charged for=20 the visit. The penalty is intended to ensure that=20 hospitals are not inappropriately used, when other,=20 smaller and cheaper facilities will do. A visit to a=20 small clinic costs around R30 while a visit to a=20 hospital like Baragwanath costs R120.
This applies to everybody and follows Health Minister=20 Dr Nkosazana Zuma’s injunction to the committee that=20 access to the basic package of primary health care had=20 to be universal.
Those on medical aids or insurances, or those who are=20 simply very wealthy, still have the choice of going to=20 their private practitioner — or traditional healer –=20 or using a state facility.
However, everybody will have access to the cheaper=20 drugs on the essential drugs list for primary health=20 care need if they can get their doctors to prescribe=20 them. They will be available from pharmacists who would=20 not be allowed to charge on their usual mark-up system=20 for those particular drugs. They can recover costs and=20 charge a small dispensing fee.=20
If patients can persuade their doctors to prescribe=20 from the list — their drug bills will be diminished.
Medical aids who will want to keep their costs down,=20 will encourage prescribing of those drugs and other=20 generic substitutes where they apply.
To cope with the chronic and serious shortage of staff,=20 the report proposes firstly addressing the salaries=20 issue among health staff so that competent public=20 health care personnel will stay in the game. Then it=20 proposes to gradually introduce a system of=20 accreditation for private practitioners who could then=20 contract with the district health authority to supply=20 some of the primary health care services. It hopes too,=20 to contract private GPs to do “sessions” at public=20 facilities at attractive rates. The report remarks that=20 this has been an area open to abuse in the past — but=20 newer controls, they hope will curtail abuse.
It makes two contraversial proposes — but says they=20 ought to be further explored: medical schools should=20 change their selection processes so that more people=20 from rural areas can train as doctors, as they are more=20 likely to return to those areas that their urban=20 counterparts. And it suggests measures (which several=20 government have suggested in the past) that students be=20 required to do some form of national service or pay=20 back their fees.
Doctors contracted to the authority will in all=20 likelyhood be paid by a system of capitation — which=20 means they would get a sum of money per patient=20 registered — and not be paid for each visit by each=20 patient. This assumes that there would not be as many=20 visits to doctors contracted to the DHA as there are in=20 the private sector.
But importantly evidence in the committee showed that=20 20 percent of a sample surveyed, were refused treatment=20 because they could not pay.
So the committee has bargained on the notion that=20 public sector visits will increase.
With the process now open for discussion for the next=20 two months — the most contraversial sections are those=20 which affect the private sector.
The most ticklish questions — those surrounding how=20 the money will be recouped — have been left for the=20 politicians to sort out.
The committee has made recommendations which will mean=20 that consumers who are employees will all have to be=20 covered by some form of basic hospital plan. There are=20 to be, according to the report, restrictions re-imposed=20 on medical aids which were scrapped a couple of years=20 ago — and which have lead to distortions in the=20 industry. According to those proposals medical schemes=20 will not be able to exclude the sickly or the elderly.=20 An equalisation fund will be created to ensure that=20 those funds carrying a larger risk burden, can draw on=20 the fund.=20
According to the report, the monthly costs of the=20 compulsory hospital plan will be born by both employees=20 and employers. The amount of tax that is deducted for=20 these expenses at the moment, could be drastically=20 curtailed — with wealthier members proportionately=20 getting less of the available amount deducted from=20 their income tax.
Members of these plans will be encouraged to use state=20 hospitals when they need hospitalisation — which the=20 schemes will pay for.
Behind much of what the report has recommended is the=20 notion that competition between the private and public=20 sectors — and within both sectors — will help keep=20 costs down. The private hospitals, feeling competition=20 from the public facilities, the theory goes, will have=20 an incentive to cut costs. And the public facilities=20 will have to jack up their service to attract the fee- paying private patients. The hospitals, which would=20 become much more autonomous than they are at present,=20 would have the use of those fees to put back into their=20
Some health care analysts, however, believe that not=20 enough has been specified in the plan to ensure that=20 private health care costs — which contribute the=20 lion’s share of the 8,5 percent portion of the GDP that=20 health costs — do not continue to spiral.
These critics believe that public health sector’s=20 portion of the 8,5 percent health component of the GDP=20 will go up and with no measures to cut down the=20 spending in the private sector — health could end up=20 taking up 10 percent of the GDP. The only other=20 country in the world with such a high health component=20 of a GDP, is the USA.
Paying for the proposals has been left to the=20 government and cabinet. The committee looked at the=20 size of the gap between what the government already=20 puts into primary health care, and what would be needed=20 with the new plan.
Next year some R350million would be needed to fund the=20 more urgent measures taken. But by the year 2000, this=20 amount will have become R3-billion at 1995 prices — a=20 total in that year of close to R10billion to be spent=20 on primary health care.
Several options have been put forward to fund this gap=20 — they all amount to taxing those with an income.
The possibilities range from a levy on the=20 contributions to medical aids or similar schemes which=20 would be used for primary health care costs, to a=20 payroll tax. They include the idea of dedicated health=20 expenditure from the normal tax revenue and the=20 possibility of health costs being funded from levies=20 and other duties.
For those looking for traces of the now-demonised=20 Australian health economist, Dr John Deeble, who=20 contributed in large part to the committee’s=20 deliberations, and to the country’s debate, those=20 wishing to find no traces of his ideas, believe his=20 notions have all but perished.
But for those with the same ideals as he has –=20 expressed by the minister of health in her briefing to=20 the committee — which amount to seeking a redress in=20 the inequities of our health system with a=20 redistribution of resources and universal access to=20 basic care, it’s all there.