Health Systems Trust Equity Gauge Project: briefing; Medicines & Related Substances Amendment Bill: deliberations

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21 October 2002
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Meeting report

HEALTH PORTFOLIO COMMITTEE
22 October 2002
HEALTH SYSTEMS TRUST EQUITY GAUGE PROJECT: BRIEFING; MEDICINES AND RELATED SUBSTANCES AMENDMENT BILL: DELIBERATIONS

Chairperson
Mr. L.V Ngculu (ANC)

Documents Handed Out
The Health Systems Trust Presentation
Medicines and Related Substances Amendment Bill [B40-2002]

SUMMARY
Health Systems Trust informed the Committee that the private sector expenditure in 2000 was R3898 per person, which was almost five times the public sector expenditure of R779 per person, and that less than 1 in 5 people had medical aid coverage. The Committee heard that 70% of whites have medical aid coverage whilst less than 10% of Africans had the same facility. There was far higher infant mortality rates among the blacks than the whites. The Committee was informed that due to Aids it was expected that by the year 2010 life expectancy would have dropped by as much as 20 years.

The Committee deliberated further on the Medicines and Related Substances Amendment Bill.

MINUTES
The Chair informed the Committee that there were two items on the agenda. He reminded members that the Committee was due for its Eastern Cape tour and that it would be important for members to be informed on issues.

The Chair said that to highlight some of these areas of concern, the Health Systems Trust Equity Gauge Project (the Trust) would make a presentation to the Committee. He clarified that members would have ample opportunity to interact with the Trust in the near future but that this presentation was merely to introduce members to some important issues.

The Chair then alerted members to the presence in the house of members of the Health Portfolio Committee from Zambia. He noted that Zambia and South Africa share a common heritage and that the Committee would reciprocate the visit at some point in the future.

Briefing by Ms Antoinette Ntuli
Ms Ntuli informed the Committee that the main objective of the Trust was to actively monitor equity in health and health care. The Trust supported legislators in utilising equity oriented information and analysing health policy especially with regard to budgeting and resource allocation.

The Trust helped to instil the notion of monitoring equity as a key strategy for the promotion of equity among the media and the general population of South Africa. The Trust had devised a pilot mechanism whereby disadvantaged communities could utilise information to better advocate for improvement in equity and meeting of health needs. She further informed the Committee that the Trust stimulated responsiveness of legislators, local councillors and service providers to needs identified by their communities.

The private sector expenditure in 2000 was R3898 per person, which is almost five times the public sector expenditure of R779 per person, and that less than 1 in 5 people have medical aid coverage. She noted that 70% of whites have medical aid coverage whilst less than 10% of Africans have the same facility. She revealed that there were far higher infant mortality rates among the blacks than the whites.

Ms Ntuli pointed out that per capita expenditure was below R650 in four provinces while it was more than 1200 in the Western Cape. She explained that at times inequities within provinces was even greater, with some districts spending as much as four times more than others per person on health care. A survey of households affected by Aids found out that they spend on average a third of their income on healthcare with some rural families' spending half of their income on health care alone.
In the Eastern Cape and Northern Province there were 12 medical practitioners per 100,000 people as compared with 32 in the Western Cape and that between 60% and 70% of spending is on salaries. There was also evidence that AIDS was worsening the poverty situation noting that estimates as to HIV related bed occupancy in hospitals were as high as 60%. She pointed out that it was expected that by the year 2010 the life expectancy would have dropped by as much as 20 years.

Ms Ntuli recommended strong measures to strengthen the public health system as a whole noting that there was also a need for clarity on the way forward to contain the impact of HIV/Aids especially with regard to ART and ensuring access to cheap medicines. She advocated for opportunities to strengthen public/private partnerships as a vehicle for providing care.

Ms Ntuli concluded her presentation by emphasis the fact that the response to HIV/Aids had to be multi-sectoral and include poverty reduction strategies as well as measures designed to improve access to basic facilities, especially sanitation.

Discussion
Mrs Mnumzana (ANC) observed that the high expenditure on health care that has been reflected for the KZN province was concentrated in the urban centres since the rural people were faced with numerous problems. She asked if the many infrastructural deficiencies, which the Committee noted in the province, had improved since the members' last visit to the province.

Ms Ntuli agreed with Ms Mnumzana that most rural people in the KZN province were no better off than their counterparts in the Eastern Cape. The Trust carried out surveys after several years and she was not in a position to update the committee on the infrastructural situation at this point in time

Dr. Rabinowitz (IFP) questioned the logic of the recommendation that there should be an interim partnership between the private sector and the public sector when the contrary should be the case.

Ms Ntuli clarified that she did not imply that the partnership between the private and the public sectors be on an interim basis. She pointed out that quite to the contrary this important partnership should be expanded to cover more fields of human endeavour.

Dr. Rabinowitz asked if there was a possibility for rural people to be afforded with free water supply.

Ms Ntuli replied that in fact a survey had revealed that rural people were for the most part exposed to high levels of access to water and that the main problem that afflict the rural people is the one to do with the provision of functional sanitation.

Ms Kalyan (DP) noted that there was a high mortality rates in the country and wanted to know the exact cause of this phenomenon.

Ms Ntuli explained that what has contributed to the high incidence of infant mortality rate in the recent passed was the onset of the HIV/Aids pandemic.

Ms Kalyan asked if the NGO sector was playing any role in the process of ensuring equity in the provision of health services.

Ms Ntuli replied in the affirmative explaining however that the government had the central responsibility to drive equity programs before the NGO sector could step in to augment these efforts.

The Chair noted that the findings in the report tended to confirm the sad fact that some of the government's policies had all along been wrong. These were policy challenges that needed to engage Parliamentarians and government alike.

Deliberations on the Medicines and Related Substances Amendment Bill [B40-2002]
The Chair suggested that members run through the Bill clause by clause and that parties would put to the table whatever amendments they might have. He noted that some parties had suggested amendments that were in the principal Act but which were not the subject of review at present. He invited the Legal advisor to give guidance as to whether it was proper to introduce amendments to sections in the principal Act, which was not part of the review process.

The Legal advisor replied in the negative. He explained that for any amendments to be introduced they must be accompanied by a cabinet memo and that therefore one could not introduce amendments outside what was accompanying the cabinet memo.

The Chair alerted members to this clarification and directed that only those amendments that touch on the areas that were currently a subject of review would be entertained.

Mrs Baloyi (ANC) proposed an amendment to section 1 (a), which was agreed upon. She also proposed to delete line 17 1(c), which she said, had been taken care of in the principal Act and this proposal was also endorsed by members.

Dr. Cachalia (ANC) proposed that there be an insertion in section 4(18C) Line 33 after the words medicines the following: "and such regulations shall also provide for an enforceable Code of Practice."

Dr. Gouws (NNP) offered to withdraw his proposal on the strength that it was virtually the same as that tabled by Dr. Cachalia.

Ms Kalayan (DP) indicated that she would go with the ANC proposal since it was similar to what she had formulated.

Dr. Rabinowitz (IFP) noted that the amendment would ensure that people in the profession were properly regulated and not to exclude anyone and to that extend the amendment was acceptable to her.

Dr. Jassat (ANC) proposed an insertion at section 6(b) (22C) in line 54 after the word medicine the words "or medical device" which proposal was agreed to by members. He also proposed a similar insertion at line 6(b) line 56, which was, again endorsed by members.

Ms Mnumzana (ANC) proposed an insertion in line 24 section 22 F (3) Act 90, 97 the word "and shall inform the persons prescribing the medicines of the substitution referred to in 22f(1)(a)"

Dr. Rabinowitz (IFP) suggested that the entire section 22(c) be deleted to remove the power of issuance of licenses from the Director-General. She suggested that this power should be vested in the various health profession bodies.

The Chair clarified that the health professions were regulatory bodies that did not have the competence to exercise executive decisions. He said that such authority was vested in the executive arm of the government that is represented by the D-G.

Dr. Rabinowitz withdrew her proposal in view of the clarification by the Chair.

The Chair noted that it had earlier been decided that the phrase 'medical devices' whenever it appears must be retained in the Act.

Mrs Kalyan (DP) suggested that at section 22C B (2) line 6 the word 'after' should be replaced by 'in' consultation. The pharmaceutical industry was presently excluded from the pricing committee and it made no sense that the biggest role player had no input in its own industry.

Dr. Gouws (NNP) expressed the view that each professional council should be left to regulate its own members.

Mrs Mnumzana (ANC) pointed out that this issue had been exhaustively debated before and that the term 'in consultation' was sufficiently explained to the Committee.

Dr. Luthuli (ANC) concurred with Ms Mnumzana that the meaning of 'in consultation' meant that the decision might end up not being implemented in case of a failure in consensus. She added that it would be unfair to run huge institutions on the basis of consultations.

Mr. Nefolovhodwe (AZAPO) stated that issues were being complicated for no good reason whatsoever. He explained that the words 'in' and 'after' were mere technical terms and that the former term was not practical in where one wanted to effectively run public institutions

Mrs Baloyi pointed out that this was an area where the pharmacy council was clothed with the requisite competence to regulate and that it was important for other players to respect their decision.

The DG stated that with a clarification that the pharmacy council only set the curriculum but that it was upon the other health professions to run the programs. He emphasised that this was an important distinction to make.

The Chair noted that there was a general view that the word 'after' be retained and asked Mrs Kalyan if she still stood by her proposal.

Mrs Kalyan insisted on the term 'in' noting that it was only fair that all role players should be carried on board.

Mr. Gouws, too, indicated that he stayed with his position.

The Chair directed that the amendment be flagged for the meantime and that the Committee moved to the next section.

Mrs Mnumzama proposed another technical amendment to the effect that at section 22 F (3) line 24 the following words to be inserted - "and shall inform the persons prescribing the medicines of the substitution referred to in 22f(1)(a)"

Dr. Rabinowitz protested that the proposed amendment was impractical in real practice.

The Chair explained that the amendment would take care of a situation where the pharmacist dispensed a different generic drug - possibly a cheaper one - to the patient from the one initially prescribed by the doctor. He added that this information was important for the doctor's record.

Mr. Nevefolovhodwe (AZAPO) registered his agreement with the Chair's reasoning. He pointed out that unscrupulous people were fond of convincing patients to buy their drugs when such drugs were not completely appropriate and the only reason for changing the prescription was to clear the stock.

Dr. Cachalia (ANC) pointed out that once the relevant authorities had branded a drug, a pharmacist was free to dispense it to patients even where such prescription was different from what the one the doctor prescribed.

Ms Tswete (ANC) wondered how one could ensure that the pharmacist did not undermine the doctor's prescription.

Dr. Rabinowitz suggested that the change of prescription should only be allowed with the doctor's approval.

Dr. Gouws (NNP) cautioned against putting this responsibility on the pharmacist to inform the doctor, a situation that was laborious in far-flung rural areas.

Ms Kalyan said she was in agreement with the amendment but was concerned about the aspect of legal liability, which Dr. Gouws had alluded to.

Dr. Jassat (ANC) pointed out that the patient had an option to accept or reject the change of prescription.

The Chair explained that it was important for the doctor and the patient to be informed of the availability of cheaper drugs so that the patient could make an informed choice and that once the patient made that kind of choice the pharmacist would be released from liability. He however questioned the introduction of the issue of liability in this case.

Mrs Baloyi (ANC) explained that the issue of liability could only come in where there had been professional negligence and that once a drug had been branded there should be no question of liability in dispensing it in the prescribed manner.

The Chair agreed with Mrs Baloyi's explanation which he said had clarified the issue. He pointed out that the question of generics and the cost factor could not be separated and that the purposes of this clause was to allow patients to access low cost drugs from pharmacists.

The Chair called on members to converge again on 24 October 2002 to continue deliberations on the Bill. The meeting was adjourned.

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