Health Charter: Department briefing

Meeting report

HEALTH PORTFOLIO COMMITTEE
2 August 2005
HEALTH CHARTER: DEPARTMENT BRIEFING

Chairperson: Mr L Ngculu (ANC)

Documents handed out:
Department PowerPoint presentation on the Health Charter
The Charter of the Public and Private Health Sectors of SA

SUMMARY
The Department of Health briefed the Committee on the Health Charter, outlining the four main principles, namely access to healthcare, equity, quality and broad-based black economic empowerment. The Charter outlined a number of proposals being investigated. Developing a low-cost health service for low and middle-income groups, and low-cost insurance options were priorities.

The Committee raised questions concerning medical scheme governance, the escalating costs of healthcare, the poor treatment of non-paying patients in some hospitals, skills training, and ensuring that personnel stayed in the country. Members felt that they needed to study the document further and have more discussion with the Department.

MINUTES
The Chairperson explained that a Committee representative had been unable to attend the launch of the Health Charter two weeks earlier. Thus he had requested the Department to present the report to the Committee.

Department briefing
Dr K Chetty (Department Deputy Director-General) briefed the Committee on the Health Charter. The Minister had convened a task team comprised of representatives of the private and public sector, including trade unions. The Charter outlined four key principles: access to healthcare services, equity in healthcare, quality of healthcare and broad based black economic empowerment.

The Charter mapped out problem areas. Under the issue of access, Dr Chetty illustrated how access to medical schemes had diminished. Inadequate access to low-cost services was an essential issue. Private healthcare had become increasingly unaffordable, while its administration costs had escalated.

The second principle highlighted great inequity between health services. Resources of R33.2 billion in the public sector served 37.9 million people, a per capita expenditure of R875. On the other hand, R43 billion in the private sector served 6.9 million people, a per capita expenditure of over R6 000. Medical scheme benefits paid to private hospitals had increased and those to public hospitals had decreased.

Dr Chetty emphasised that low-cost options should not mean low quality options. Regarding broad-based black economic empowerment (B-BBEE), the Charter outlined strategies such as Public-Private Sector Interactions (PPIs) and stressed that the public sector must be strengthened.

The document proposed a number of solutions and resolutions. One option regarding access, was to investigate the feasibility of contracting independent healthcare practitioners to the state, who could assist in rural and under-serviced areas.

Recommended equity targets had also been proposed. By 2010, 60% of the workplace would be black and 50% women. By 2014, it would be 70% and 60% respectively. With regards to quality of care, Dr Chetty stressed developing a low-cost health service for low and middle-income groups and the need for low-cost insurance options.

The B-BBEE principle covered procurement targets for 2010 and 2014 of 60% and 80% respectively. Private sector expenditure on social responsibility projects had to be increased and development institutes needed to be approached to finance projects.

Dr Chetty outlined the implementation process, emphasising flexibility, monitoring and the need for the Health Charter to go beyond previous such goal plans. The Department felt that the higher targets outlined were achievable. The deadline for inputs on the document was August 15. The Department had received positive responses from stakeholders, who wished to frankly discuss what was achievable and realistic. The diverse task team had worked together well with good co-operation between the public and private sectors.

Discussion
Mr S Njikelana (ANC) noted that the Charter listed ‘sociological’ as one of the factors causing inadequate access to health services, and asked for clarification.

Dr D Pearmain (Department Chief Director of Legal Services) responded that the Charter had wanted to look at barriers to access as broadly as possible. Sociological factors could impair access for groups such as women, and could impair the public’s access to information such as when clinics were open. Socio-economic factors could affect people’s ability to pay for services.

Mr Njikelana pointed to the issue of diminishing membership of medical aid schemes. He queried whether members of schemes influenced how they were run. He also raised the importance of community involvement in ensuring quality of healthcare. Community Health Forums and Hospital Boards were important sites for receiving vital feedback from the community.

Dr Chetty agreed and raised the importance of community governance to ensure quality. Community participation was a legal requirement under the National Health Act but the Charter wanted to go further. There was a need to look at governance issues in the private sector. Medical scheme membership was unrepresentative as the majority of members were white people. The issue of how to capacitate Trustees in the governance of medical schemes had to be further addressed.

Ms M Madumise (ANC) wanted to know how the Department would encourage private practitioners to contract to the state. Dr Chetty responded that a feasibility study would be conducted. ‘Practitioners’ referred to all healthcare workers and not just General Practitioners (GPs).

Ms Madumise queried whether funding from the state went to both the public and private sectors. Dr Chetty responded that the public sector was funded from National Revenue Funds. ‘Out of pocket’ and medical scheme expenditures funded the private sector. However, because the state subsidised through taxes, the rich were subsidised more than the poor,

Dr Pearmain elaborated that employer and employee contributions to medical schemes were taxed and the contributors received a tax break, hence affording them a government subsidy.

Ms B Ngcobo wanted to know if the Charter included traditional health practitioners in the category of practitioners. Dr Chetty responded that once the Interim Council of Traditional Health Practitioners had worked out what qualifications were required and these became regulations, traditional practitioners would be deployed where necessary.

Dr A Luthuli expressed concern about the escalating costs of healthcare and medicines. She questioned how the Health Charter proposed to bring costs down. Dr Chetty replied that even the private sector was concerned with escalating costs as it effected their business. Unemployed people, pensioners, pregnant women and children under the age of six received free healthcare in the public sector. For other patients, earnings determined payment. The Department continually reviewed the issue of affordability. If the outpatient fee schedule was too high, then it needed to be reviewed.

Dr Pearmain noted that in terms of private sector expenditure, the ‘size of the cake’ had not grown over the past few years. The relatively recent introduction of medical scheme brokers had resulted in the same pool of members being ‘churned’ between different schemes, with brokers being enriched on the commissions. The introduction of more non-medical services within the schemes, with questionable benefits to members, had resulted in increasing administrative costs. The prices of the schemes then went up with no increased medical benefits.

Mr I Cachalia (ANC) raised the difficulty of achieving ‘low-cost options that were not low quality options’, considering that medical scheme membership had been diminishing, medical costs increasing and more cases of fraud occurring within medical schemes.

Dr Chetty agreed and said that a minimum defined medical scheme package needed to be investigated. Those that could afford it could then top up with extra features. Dr Pearmain added that the medical aid industry now had a fraud unit investigating cases.

Mr Cachalia wanted the Department to address the issue of emergency medical treatment in cases where poor patients were being turned away from private hospitals.

Dr Pearmain noted that many private hospitals took in emergency patients in order to stabilise them. Intensive Care Units (ICUs) in the private sector were very costly and these hospitals could not afford to take on too many cases after stabilisation. In some cases, the public hospitals paid the private sector for such treatment. The private hospitals were aware that they were obligated to admit emergency patients, though it was true that there had been cases where patients had been refused treatment.

Ms P Tshwete (ANC) asked what strategies had been proposed to encourage students to join the health services. Dr Chetty noted that the detailed document contained a sector marketing campaign and career guidance campaign to reach students. There were many other medical professions needing to be filled besides doctors and nurses, and it was also important that students learned about these.

Ms Madumise questioned skills development and shortages. Dr Pearmain acknowledged that this problem was being addressed. Sector Education and Training Authority (SETA) funding was being used to train personnel in terms of the Health Care Act. While no detailed solutions were currently available, it was important to find ways of keeping skilled healthcare practitioners in the country. Highly trained ICU and theatre nurses in particular were emigrating. Government bursary schemes required the recipient to work a number of years at state hospitals or pay back the bursary money.

Ms Ngcobo wanted to know how the Charter was being ‘popularised’. She also asked whether interdepartmental engagement had taken place to address sociological and other issues. She wanted to know how the Charter rated with the World Health Organisation (WHO).

Dr Chetty distinguished between the already published Patient Charter, which was widely publicised, and the Health Charter. Interdepartmental engagement would be improved after the August 15 deadline. The WHO rating for South Africa had been poor and was a primary reason for the Health Charter being written.

Dr Pearmain noted that the Health Charter was a social contract between the public and private sectors to achieve certain targets. It had not been finally approved or agreed upon and was still up for discussion. Stakeholder comments would be received by the August 15 deadline, whereupon the Minister would propose a way forward.

The Chairperson felt inequity between the provinces had not been addressed clearly in the document. He also questioned the strategies for achieving the proposed targets. A more scientific basis of arriving at targets was needed. His experience on the ground was very different from the proposed document observations, and he questioned how its proposals translated in practical terms. Many of his constituents had related examples of ambulances refusing to transport non-paying victims from accident scenes to hospitals. Township residents had told of very bad staff attitudes in certain hospitals. He felt the Committee needed to study the Charter document more thoroughly and have further opportunity for discussion.

Dr Chetty responded that further discussion would certainly be possible. As inputs from stakeholders were received, the task team would have a clearer idea of figures, targets and recommendations. Provincial inequities certainly needed to be further addressed.

The Chairperson thanked the presenters for a valuable first presentation of the Health Charter.

The meeting was adjourned.