The Committee was briefed on the structure and purpose of the Hospital Association of South Africa (HASA). The three major private hospital groups were members, and 90% of all private hospitals were members. About 15% of the South African population belonged to medical aid schemes although almost half the population would make use of the services of the private health sector as a whole. Private hospitals were obliged to accept patients in an emergency, stabilise their condition and accommodate them until they could be transferred to a public hospital. Plans had been made for the 2010 World Cup although there had been little communication with the Department of Health.
The Association consulted with the Department of Health and saw itself as a bridge between the private and public sectors. It controlled the affairs of its members and took disciplinary action when necessary.
Members questioned the prices charged by private hospitals. A reference price list was used for procedures although the different hospitals had to observe anti-competitive legislation. It was accepted that private hospitals existed by making profit. There were some initiatives to give back to the community. Members stressed the need for good primary health care and criticised private hospitals for their lack of service in this regard. The public sector had some advantage in tenders but even they had incurred massive cost overruns in the recent past.
Medical personnel were in short supply. The private sector was providing some training but this was limited.
The Deans of Faculties for Health Sciences had been invited to the meeting, but the e-mail had been sent to an old address and the invitation had not been received in time. The Chairperson noted that it was the anniversary of the death of Florence Nightingale. The day was celebrated as International Nurses Day. All nurses were requested to give a hundred minutes of service on the day. He said the Committee should write to the Department of Health (DoH) to congratulate the country's nurses for their good work.
The Chairperson said the role of Parliament to work towards improving the health of the people. In recent years the population had increased from 45 million to 49 million despite predictions that the HIV/AIDS epidemic would curtail population growth. Infant and maternal mortality rates remained unacceptably high. Unlike the rest of the world, South Africans suffered more from infectious conditions such as HIV/AIDS and tuberculosis than from degenerative diseases. There was a big gap between the poor and the rich. The people served by the HASA delegation were those who could afford private health care.
Mr Goqwana said that the anomaly of health care was illustrated by a recent assault where the baby was taken to one hospital and her caregiver to another. He was not asking that HASA's constituents should not make a profit. How could they work with government to reduce the infant and maternal mortality rate? He did not want to discuss the proposed national health insurance (NHS) scheme at this meeting. He did notice that the private medical sector took little responsibility for primary health care as this was not profitable. Innovative ways had to be found to deal with this situation. In the Northern Cape people had to travel 1000km to visit a hospital. There was an even more desperate situation in the Eastern Cape.
Hospital Association of South Africa
Adv Kurt Worrall-Clare, Chief Executive Officer, HASA, said that all the team members were experts in their field. HASA was a non-profit organisation. It represented 90% of the country's private hospitals including all three of the major hospital groups, as well as a number of independent hospitals. They recognised the leadership of the Department of Health (DoH). There was good synergy with the Department, especially of late. They consulted with DoH on a wide variety of issues. HASA had a code of ethics which was an evolving document. They had requested an input from DoH. HASA was a responsible resource for the betterment of health care. They were open to discuss the NHI. It would help to bridge the divide between private and public health care.
Dr Victor L Litlhakanyane, Board Member, HASA, said that 50% of the population made use of the private sector by visiting a general practitioner (GP). Of these, 15 million used the private sector for primary health care and 9.5 million for secondary and tertiary care. The various medical schemes had a combined membership of approximately 8 million. Some people paid cash to use private medical facilities. There was a focus on hospital care but some of the groups provided some primary care. There was no focus on the good work being done by the private sector. Some R30 million was spent annually on needy patients. HASA members ran programmes for the poor. These received little publicity as the public seemed to enjoy bad news more than good news.
He said that in terms of the Health Sector Charter, there were instances where private hospitals were obliged to treat state patients. It might happen that the cost of hospitalisation might exceed the medical aid scheme member's prescribed minimum benefits (PMB). In this case the private hospital had the right to transfer the patient to a public hospital for further treatment. Proper contracts were not in place with the provinces. The medical aid scheme for Transnet members made provision for some public sector care.
Mr Litlhakanyane said private hospitals were obliged to offer emergency treatment to all patients at their own cost. Patients without medical aid would be stabilised and treated at the private hospital until a room could be found in a public hospital. There was also a divert arrangement where patients would be treated in a private hospital if there was no room available at a public facility. It was not true that patients were dumped at public hospitals. At present there were no published terms or conditions governing the diversion of patients from public to private hospitals or the transfer from private to public. A protocol had to be developed. HASA members did not discriminate between those patients with or without PMB. HASA felt that PBM should expand to cover all hospitalisation costs.
He said that HASA members were not allowed to discuss prices. These could be negotiated. Patients were billed for all services and material provided. Per diems were charged for the duration of the patient's stay. Doctors treating patients were responsible for their own pricing.
Ms Melanie da Costa, HASA Board Member, said members set package fees on a daily basis. These fees were all inclusive. An alternative approach was to charge a fixed fee for the whole procedure.
Mr Litlhakanyane said HASA was moving towards a different pricing system. Of all medical expenditure in the country, 32% went into hospitalisation. This was comparable with other countries. South African pricing compared well globally. Out-of-pocket expenses were lower than in many other countries. Section 90 of the National Health Act (NHA) made provision for a reference price list (RPL). This was not mandatory but gave patients an indication of what they might have to pay. HASA had worked hard with consultants to get their prices right. He felt that the DoH should go through the same exercise to determine the cost of procedures in the public sector. There was no proper costing.
Dr Nkaki Matlala, HASA Chairperson, said that HASA was doing many good things. They had gone to public tertiary hospitals and offered to assist with reducing their backlogs. It was difficult to work out a price to charge for these procedures as the state did not know what the actual costs. Members must have a look at the RPL. The uncertainty over costs made health care difficult. They needed to get a benchmark.
Mr Litlhakanyane said they needed to find a solution. HASA had approached the DoH. There was an issue of the ageing medical aid population. Young people were not taking out cover. The practice of risk pooling was being eroded. Some schemes catered mainly for the old and sick while others leaned towards the young and fit. The more contributing members, the lower the cost would be. On the subject of VAT, savings could be achieved by zero-rating medical products and services. The Health Professionals Council of South Africa (HPCSA) suggested that doctors should be employed by the medical aid schemes to bring down costs. Government medical institutions bought their medical supplies on state tenders while the private sector paid a premium. A number of measures had been proposed.
Dr Matlala spoke on the subject of 2010 readiness. HASA had been invited to several meetings. However, the past ten months had been difficult. Most of the planned meetings had been cancelled. Nevertheless, HASA members were readying themselves for the World Cup. Internal readiness plans had been drafted. There had been ad hoc meetings with the DoH and provincial health departments. There was no agreement yet. The World Cup was the biggest event in the world. It would be played in winter and HASA members would have to provide medical care.
HASA members were committed to admitting emergency cases. He anticipated an increased need. There was an opportunity to forge new relations between the private and public sectors. This would leave a legacy. Most private hospitals had trained their staff. Major Incident Committees had been established at hospitals. Generic plans had been developed within each group customised for the individual hospitals. Operational plans had been drawn up for match days. Some hospitals near training venues had been identified as the venue of choice. Ordinary operations must continue on a daily basis.
There was an agreement on targets. The hospitals needed to know what the priorities for treatment were. There would be forensic demands posed by investigation of human trafficking. Fortunately, most of the visiting countries would be well informed. Disaster readiness was a huge area of focus. The triage would determine the acuity of a patient. Clinical surveillance would provide information about disease and injury profiles. There had been a lot of interaction on this lately. Epidemiology would focus on both incoming visitors and locals. There was a lack of communication but this was improving. The National Command Centre would be located in Pretoria.
Many private hospitals were keeping information on delivery and clinical care. Until now there had been no clear communications plan with the DoH. Nurses had been identified who were earmarked for the private hospitals. The World Health Organisation (WHO) would pay for them. Their task would be to gather date for the Command Centre. The reporting procedure had to be finalised shortly.
Dr Matlala said HASA needed a list of support hospitals. Some of these might be next to the stadiums. Lists had been compiled before the sites for the stadiums had been identified. There was an agreement that the private and public sectors would co-operate. The same rates would be charged as for injuries on duty (IOD) but there was still no agreement. Legacy targets could only be developed after continuous public/private interaction. HASA wished to assure the Committee that it would co-operate.
The Chairperson asked where HASA saw itself in the next twenty years. Some of the health problems in the country were related to the inequities. He used the example of a miner who was diagnosed as HIV positive. While working for the mine he enjoyed good medical care. However, he was later retrenched and returned to his home village in the rural areas. There his medical care was considerably downgraded. Relations between the two sectors were working well in areas such as the Eastern Cape and Gauteng. The Committee had received no progress report. It was government policy to foster public/private partnerships (PPPs). He did not know how much primary medical care was provided in private hospitals. He asked if there were any initiatives.
Dr Matlala confirmed that a detailed report on HASA had been prepared in 2008/09.
Ms da Costa said there had been reviews of private hospitals in 2008 and 2009.
Dr Matlala said that South Africa had led the way in medical history. The country had been the venue for the first heart transplant. South Africa had also been the first country to emphasise the need for primary health care. Without good primary health care the secondary and tertiary phases of health care would be under more pressure. His vision for twenty years time, was to have improved public health care. Private and public health care should be of the same standard. A roadmap had been developed in 2008 in the form of a ten-point plan. Government produced beautiful policies but lacked the human resources and management to put them into practice. The current problem was poor primary health care. However, primary health care was not the area of focus for HASA members. They concentrated on secondary and tertiary care. However, primary care was relevant.
The Chairperson asked how South Africa's situation could be improved. It was government policy to improve the level of primary health care.
Ms da Costa said she had visited Brazil where there was more integration between the private and public sectors. Spending on private medical care was at about the same level as in South Africa. The Brazilian health department outsourced about 70% of health care to the private sector. Private companies were allowed to employ doctors. People had the option of using a national network of health care. Her vision was that South Africa would be at the same point of public/private co-operation in the future.
Ms da Costa said the NetCare group operated 50 hospitals in the UK. The National Health Service (NHS) in the UK used 60% of the capacity of NetCare's capacity. For example, NetCare had performed 35 000 cataract operations on behalf of the NHS. Anything was possible with the right attitude.
The Chairperson said some patients in need of emergency care had been turned away from private hospitals. In some cases patients had died while being taken to a public hospital. Members had a different impression of the pricing structure. He had heard of a private hospital charging a Swazi citizen R500 000 for an appendectomy. The impression created by such examples was that the private hospitals charged what they liked. The three groups did not have a uniform spread of prices. This needed to be sorted out.
Ms M Segale-Diswai (ANC) remarked that Members should receive copies of the presentation at least a day before the meeting. They could then interact better with the presenters. It was very important that the DoH should be present at such a meeting. She noted that HASA was a voluntary organisation. She asked who made up the 10% of private hospitals that were not HASA members. She asked how HASA was represented in the provinces. The Chairperson was correct in saying that private hospitals offered no primary health care.
Ms Segale-Diswai had a problem with the cure rate for TB. Government health care followed a certain protocol. Patients might develop resistance if they were prescribed different medicine by a private doctor or clinic. The Committee was not hearing what was happening at grassroots level. HASA said its members were obliged to provide emergency care but were often left at the door. She agreed that government hospitals did not know what the price of medical care was. She asked if there was a price schedule.
Ms Segale-Diswai asked which were the designated hospitals for 2010. There seemed to be a serious communication problem between HASA and the DoH. She asked how the PPP policy could be applied in the health care sector. Bodies must work together.
The Chairperson said that normally presenters were advised of the agenda of the meeting. No agenda had been set as this was the first such meeting with HASA and they had not been able to prepare the presentation in advance. The country could not afford not having the sectors talk to each other. Doctors were not accountable to private hospitals even though they might be using their facilities. Private health care was a profit-making enterprise. It had to be realised, however, that they had to cover research costs. There was not enough business in the rural areas to entice private hospitals outside of the major urban areas.
Ms M Dube (ANC) was worried that a patient could see what was happening but had no control over the prices. In the light of this, she asked what the purpose of HASA was. It seemed that it was all business with no concern for the patient. A patient in a private hospital might still be sick but would be transferred to a public facility when the medical aid ran out. She felt that the patient should remain in the private hospital until healthy again. Some medical aid schemes operated on yearly cycles of benefits. Private hospitals did not want to work at a loss.
Ms da Costa said that 19% of the hospitals in the country were private. They treated over 250 000 patients annually, of which 80% had medical cover. The bulk of the population lived in poverty and only 15% could afford health cover. Recently there had been good growth in employment which had seen more people joining medical schemes. Public health spending amounted to 5% and that in the private sector was 95%. The amount of patient dumping had been reduced although there was still an element.
Adv Worrall-Clare said that competition law prohibited members of the groups from comparing their prices and discounts. There used to be a negotiating platform but the anti-corruption legislation had forced this to be stopped. Hospitals were linked to medical schemes. Competitive packages were available. Some hospitals had a basic pricing model. The patient had a right to know what he or she was paying for.
Mr E Sulliman (ANC) asked who the 10% were, who were not HASA members. Less than 20% of the population had medical insurance. Government was busy with NHI and hopefully this could be introduced early in 2011. What role would the private sector would play, if any?
Dr Matlala said that some members had been long standing proponents of an NHI scheme before the ANC had adopted it as a policy. A research unit had discussed the issue at length and had looked at examples around the world. The unit had made suggestions to the Minister about which countries should be visited. The matter had been discussed since the 1940's. The status quo could not continue.
Adv Worrall-Clare said that HASA opened its membership to any private hospital in terms of the law. The legislation dated back to 1977 and was subject to reconsideration. The applicant must have a licence. HASA was trying to recognise all private institutions. Where hospitals were part of a group then all members of the group had to join. This did not apply to smaller groups of independent hospitals where not all were required to join. Often newly licensed hospitals wanted to recoup their capital costs before considering joining HASA. Membership was still growing.
Mr M Hoosen (ID) understood the profit motive. They would not exist otherwise. The private hospitals were making a significant contribution to health care, but patients with no money to pay for their services were shown the door. This happened on a daily basis. He asked how the ethics code covered this and if any action had been taken. One slide in the presentation showed how the cost of health care could be reduced. There were two components, namely cost and accessibility. There were a number of South Africans who could afford private care but who could not find the money to pay the large deposits asked before they could be admitted for a procedure. There had been a discussion with the Minister on IOD rates. He asked if these could be reduced and why this concession could not apply at other times, not just during the World Cup. He asked if there was any provision for patients to pay off debts or if only a lump sum payment was acceptable.
Adv Worrall-Clare said that ethical codes had been developed in isolation. There were separate codes of ethics for doctors, nurses and hospitals. The Acting Registrar of the HSPCSA was doing well to understand this problem and was working on it. It was a representative body which had a responsibility to educate the public. It was a misconception that penniless patients were being turned away in emergencies. It might be that a doctor based at a private hospital refused to treat a particular patient. The hospital provided the resources but it was the doctor's decision which could bring the hospital into public disrepute. There was a disciplinary procedure.
He said hospitals had amended their articles of association. They must adhere to HASA ethics. No patient could be turned away in an emergency. If the code was violated then the matter should be reported to the ethics committee. Fines could be imposed or statutory bodies could take the matter further. There were weaknesses in the legislative framework.
Adv Worrall-Clare said that he had attended the National Assembly many years previously when the NHA had been tabled. He had lobbied for the inclusion of a formal definition of an emergency in the Act. There was nothing at present and everything was a matter of interpretation. The Medical Schemes Act did have a definition but that Act followed a different approach. The Minister of Health was empowered to make regulations. It was critical for the private and public sectors to discuss fundamental issues such as the definition of an emergency, protocols and accountability. This would result in a comprehensive transfer protocol. There was a good new working relationship between the sectors although the partnership could still be more comprehensive.
He said cost reduction was governed by Regulation 158 of the old legislation. This was applicable to all private hospitals. Provincial departments licensed private hospitals. Operational licences were subject to annual renewal. All private health facilities were being lumped into one. For example, there was a regulation that a hospital corridor had to be at least two metres wide. This made sense where patients were moved on stretchers but was perhaps not relevant in a psychiatric hospital. Perhaps it was time that regulations addressed specific structures. This would contribute towards lower building and maintenance costs. Submissions had been made to the DoH to reduce costs.
Adv Worrall-Clare described the complaints process. It was a particular function of HASA. It had the facilities to investigate complaints and take members to task. Sometimes matters ended up in the press but were also often dealt with by HASA. The DoH and HPCSA referred the matter to HASA. There was always room for improvement.
The Chairperson asked if there were any other innovations.
Ms da Costa said that HASA members worked with an average profit of 15%. HASA had done a study and found that if their members made no profit at all then the reduction in medical scheme payments would only amount to 5%.
Ms A Luthuli noted that this was the first discussion of its kind. Members were at a disadvantage as they had only seen the presentation now. The comparison of South African prices was to wealthy, advanced countries. Why had there been no comparison to developed countries. This created a skewed impression. Patients were being dumped when they had no more medical aid funding. Something needed to be done as this practice was a contributing factor to the high mortality rate. A R9 000 deposit was spent so quickly. An American trend was happening here where patients were sent for many unnecessary investigations. Once a patient was admitted to hospital it seemed that every discipline wanted to have a piece of him or her. This was causing a lot of suffering.
Ms da Costa agreed that cash payments were expensive. The average cost per case was between R15 000 and R16 000. On average 95% was covered by medical aids and the balance in cash. More people would make use of private health care if it was more affordable. There was a conspiracy theory about the way patients were referred for all manner of tests. The hospitals did not employ the doctors making the diagnoses. Integration and co-ordination of services was important. Medical schemes generally felt the need to approve treatment before patients were admitted. There was case monitoring to see whether patients were being over-serviced.
Adv Worrall-Clare said patients were acutely aware of the costs. The final invoice had to be fully detailed.
The Chairperson noted that the DoH and the Council for Medical Schemes (CMS) should have been present. South Africa was a country of two worlds in one. The different sectors were not talking to each other.
Dr Matlala said that HASA was looking for answers. Health care in South Africa was in an unhappy state. The polarisation should not exist.
Ms E More (DA) said there had been a case reported in 2006. A private hospital in Soweto was found to be admitting patients for a minimum of three days as a matter of course even where this was not necessary. In terms of human resource planning, she asked if HASA foresaw the need to train more personnel. Many medical staff were trained in the public sector but migrated to the private sector.
Mr Litlhakanyane said that there could be no health care without nurses. The college in the Free State had been closed. The private sector had to increase the number of nurses being trained. There were impediments. The private sector had been following a four year programme which included midwifery. Babies were now delivered by obstetricians. Good quality nurses were being trained. They served first as assistants and then followed a specialist route. Some of the nurses being trained at universities were funded by HASA. Government's decision to cut back on training was coming back to haunt the medical sector. There was a dire shortage of nurses. Some were being shared by the public and private sectors. There was still a long way to go. The Nursing Council was reviewing the scope of training. He feared that some backward steps were being taken.
A Member commented that it was important to meet all parties. What was HASA doing to benefit primary health care? In terms of 2010 readiness she asked what role HASA would play in the HIV/AIDS awareness campaign.
Mr M Waters (DA) said there was a perception that the private sector had high costs as opposed to state medical care. This was an unfair comparison as a different quality of service was offered. In the last financial year the sum of overspending at provincial level was R12 billion. It was a fact that the cost of health care was increasing. The main drivers were the cost of human resources. The public sector had a chronic shortage of personnel. The implementation of the Occupational Specialisation Dispensation (OSD) had put further pressure on government's health budget. In the past the private sector had trained half of the nurses but was now subject to restrictions. More nurses were needed. The universities had no more capacity to train doctors. In Colombia the private sector had been allowed to open medical schools and that country now had 58 medical schools compared to South Africa's eight or seven. A result of this, Colombia was now able to export doctors. South Africa was exporting medical staff, but that was another matter.
Mr Waters asked if the Committee could be briefed on the unpacking of basic costing issues. The quality and access to medical treatment should be considered. The Minister was going to Brazil. The Committee needed to be briefed on his findings. The NHI was only a funding model. Structural change might be needed. Visiting experts should brief the Committee.
The Chairperson was not sure that there was a shortage of doctors in the country. It might be the case in the public sector. GPs were not being utilised fully. In some small towns there were two or three GPs practising.
Mr Datlekanyane said that the number of doctors being trained was not increasing. Half of those who completed their studies immigrated. Doctors could be used more effectively. They had noted the work being done in Colombia and had gone to the previous Minister to ask that this model be adopted in South Africa. The request was declined. HASA was providing funding and bursaries for students. Government did not want to see students being exposed to the public sector during their training. There was a need for an open debate on this matter. There were seven medical schools in the country and the numbers could not be expanded. The private sector was training other health professionals such as therapists. He did not think that health professionals were paid better in the private sector but one had to look at the whole package. Working conditions were also factors.
Ms T Kenye (ANC) asked how private hospitals were reimbursed for handling emergency cases. This emphasised the need for a PPP. She was surprised that the public was aware of HASA. There was no HASA presence in her home town. Talk shows were needed to communicate the role of HASA to the people. The proper solutions would then become visible. She found the number of meetings regarding 2010 preparedness that were cancelled to be a contradiction. She asked how the medical sector could regard itself as prepared if the meetings did not take place.
The Chairperson asked how they were connecting. He asked if HASA was working through the Director-General of the DoH.
Ms Dube asked about the 10% of hospitals that were not members of HASA. She asked if all hospitals in the NetCare group were members. She asked to see a membership list. What monitoring and inspection mechanisms were in place? The condition of some hospitals was deteriorating.
Mr P Mnguni (COPE) could not find much about the history of HASA in the document. This might have been covered in a previous presentation. He would be grateful if the documents were provided in good time. What intervention measures there were between the patient and a hospital? How far would HASA go to protect the interests of the patients? It was a grey area.
The Chairperson observed that there was not a good working relationship between GPs and the private hospitals where they based themselves. African doctors were trained at Medunsa and tended to practise in the Pretoria area while those trained at the Walter Sisulu University tended to practise in Umtata.
Dr Matlala said he was a member of the College of Medicine. This institution was responsible for the adjudication of specialists. A thousand specialists were needed each year. He would soon be meeting with the Minister. Private hospitals were prepared to offer themselves as platforms for training. Hopefully a solution would be found by the end of the year. The National Treasury was prepared to help if there was an agreement in place.
The Chairperson said that the Committee wanted to call the College of Medicine. There was a feeling that Africans could not be specialists. At the time when he had been tested he had been told that he would have to be at least twice as good as his white counterparts.
Dr Trevor Frankish, Clinical Directorate, Life Healthcare, said there would be an increased risk of disease during the World Cup because of the mass gatherings. Swine flu was one possible threat. Private hospitals had refreshed their emergency plans. All the groups had major plans in place. There had been no communication regarding co-operation between the private and public sectors during the World Cup. Meetings had been repeatedly cancelled and there had been none in the previous ten months.
Dr Frankish said much was being done at local level. There were active provincial co-ordinators in North West, the Western Cape and Mpumalanga. It would not be business as normal during the tournament. The list of designated hospitals was available. HASA had been asked to assist with HIV counselling. More than half of the testing stations were staffed by persons from private hospitals and non-government organisations. There would be campaigns in the hospitals. Testing would be for the whole package, including HIV, blood glucose and blood pressure.
Adv Worrall-Clare said that half of the testing stalls were manned by people from the private sector. HASA was facilitating the spread of information to its members. All patients would be tested. Members would make financial or human resource contributions to other initiatives. These ventures were often not publicised. Another campaign sponsored by HASA was the Right to Sight. In some areas free circumcisions were performed both for infants and older males.
He said that where hospitals were part of groups then all of the member hospitals had to join. There was no discretion. He would provide the Committee with a copy of the costing model and the membership list. These were public documents. The Nursing Council had been informed the previous week that the moratorium on nursing training had been lifted, albeit only for accredited facilities. He was not sure how this would affect new applications.
The Chairperson said this would not be the first and last meeting with HASA. The Committee did not always understand what was happening in the industry. Regular meetings would help. The Committee now knew who the contact people were. The Committee needed to see if the NHA was still serving its purpose. The government wanted to see a healthy nation. There must be open discussion. HASA should be able to justify its request for private medical faculties. The Committee needed to talk to the CMS and the individual medical aid companies. A joint meeting with the DoH was also needed.
The meeting was adjourned.
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