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HEALTH PORTFOLIO COMMITTEE
6 September 2005
ROLE OF SA MEDICAL ASSOCIATION: BRIEFING
Chairperson: Mr L Ngculu (ANC)
Documents handed out:
SAMA PowerPoint presentation
The South African Medical Association (SAMA) briefed the Committee on their role, activities, operational processes and challenges. SAMA saw the presentation as an opportunity to build their relationship with the Committee and clarify their role. They outlined their role in influencing health care policy and practices. They raised concerns about doctors leaving the profession due to poor working conditions, inadequate remuneration and over-regulation of doctors, and the need for increasing the number of black doctors. SAMA expressed concerns about the Certificate of Need. While the new legislation was important, the implementation had been challenging.
The Committee raised concerns over the dissatisfaction of doctors in both private and public sectors and the exorbitant fees and taxes required of doctors. They acknowledged SAMA’s concerns over communication and consultation problems with the Department. The transformation process in medical schools needed to be addressed. The Committee resolved to note all the issues raised by SAMA and address them further.
SA Medical Association briefing
The SA Medical Association (SAMA) briefed the Committee on their role, activities, operational processes and challenges. The SAMA team consisted of Dr A Thulare (SAMA CEO and Secretary-General), Dr B Selebano (SAMA Corporate Affairs), Dr O Setsubi (SAMA member Western Cape) and Ms M Pillay (SAMA Legal Department). SAMA considered the presentation an opportunity to build their relationship with the Committee and clarify their role.
SAMA was a voluntary association of private and public sector doctors. It had amalgamated the Medical Association of South Africa (MASA) and the Progressive Doctors Group (PDG/NAMDA) to emerge in 1999 as a new unified body with the aim of empowering doctors to bring health to the nation. SAMA became a member of the World Medical Association (WMA) and aimed to help form a Medical Association for the African continent. Public sector doctors required SAMA become affiliated to COSATU.
SAMA has been involved in anticipating and influencing health care policy and practices in both public and private spheres and had supported the Department of Health vision for a unified, coherent, affordable, accessible and quality health system. SAMA, through its organisational structure and core competencies, had positioned itself to interact with government, the legislature and stakeholders to influence that vision. The organisation had been involved in professional development and training as well as publishing materials such as the South African Medical Journal (SAMJ).
The National Health Plan and the constitutional framework’s Bill of Rights had presented SAMA with opportunities to represent the medical profession’s position. The Association had raised issues and concerns around definitions and content, legislation and regulations and implementation in the Medical Schemes Act, Medicine and Related Substances Act and the Health Professions Act. It had expressed concerns about the Certificate of Need, the National Health Reference Price List, International Coding (ICD-10), the Social Health Insurance (SHI) and Risk Equalisation Fund (REF). A basic health care package needed to be defined.
SAMA had been concerned with doctors leaving the public sector and had cited issues such as staff shortages, poor working conditions, inadequate remuneration, work overload, supervision problems, insufficient career-pathing and taxation of public sector doctors as the major reasons.
SAMA had supported the Health Charter’s identification for the need to transform the health care system at various levels and the notion of patient-centredness.
Access, equality and quality were essential areas of transformation that need to be developed through tools such as clinical guidelines and formularies; the retention of health care professionals, properly structured and sustainable Public Private Partnerships (PPPs) and Initiatives; and the strengthening of the Public Sector.
The BEE challenge had highlighted the insufficient number of black doctors including specialists being produced. There needed to be an interactive engagement between Department, HPCSA, medical universities, and other relevant academic institutions as well as SAMA and other professional associations to assist in the transformation of universities to improve the situation.
The Chairperson reminded the Committee that the Department had been asked to return for further discussion on the Health Charter and on SHI and REF. Those discussions would better equip the Committee to address SAMA’s concerns. The Members agreed, and the Chairperson requested the Committee Secretary to arrange a meeting with the Department.
Ms D Kohler-Barnard (DA) asked how doctors were reacting to community service. Dr Selebano replied that junior doctors were experiencing problems with supervision. They worked long hours due to staffing problems with little assistance from senior doctors. SAMA had found young doctors upset and angry. This was not necessarily due to community service, but rather to conditions such as poor accommodation. The principle of community service was not the problem, but rather the support services around the programme.
Dr A Luthuli (ANC) asked what the real concerns and dissatisfaction were among doctors. Dr Selebano acknowledged that both public and private sector doctors were leaving the profession. In the public sector, doctors worked long hours under difficult conditions and felt unappreciated. Accommodation was often inadequate. SAMA considered these ‘soft issues’ which should be able to be resolved. Remuneration packages needed to be improved.
Doctors in the private sector were no longer allowed to negotiate tariffs or dispense medicines, which was a particular problem in rural areas. The impact of the legislation was causing doctors to leave. The Department should have taken the medical profession into their confidence along the way. The situation was not hopeless and improved communication between doctors and the Department would go a long way to helping the situation. Dr Setsubi added that while regulations had been necessary, over regulating was exerting pressure on doctors to leave the profession.
Dr Selebano noted that understaffing and poor working conditions in the public hospitals increased the risk of malpractice occurring. The Department however, reserved the right not to assist doctors with malpractice cases. Public sector doctors were unable to afford the high cost of malpractice insurance.
Dr Thulare added that the doctor patient relationship was sacrosanct and that was jeopardised when call-centres made decisions about patients. Accountability was transferred from the patient to the profit institution. Ms Pillay noted that doctors were finding it difficult to deal with the plethora of legislation. While they understood the need for the legislation, private practices needed to be sustainable.
Ms M Madumise (ANC) asked if SAMA had been consulted on the Health Charter. Dr Selebano responded that SAMA had been invited to make submissions when the Charter was presented to stakeholders but there had not been enough time to discuss issues thoroughly with all members. Despite the time constraints, SAMA had made oral and written submissions. Dr Thulare added that during the year following the initial launch of the Charter as an idea, there was insufficient consultation between the task team and stakeholders and the process had not been transparent enough.
Ms P Tshwete (ANC) asked how Primary Health Care (PHC) packages in other countries, particularly in Africa, compared to South Africa. Dr Setsubi explained that PHC was a philosophical concept defined by the WHO. Basic health care did not in fact equal primary level care. The basic health care package was an economic concept in order to sell the product.
Mr S Njikelana (ANC) asked for solutions to the communication and consultation problems and wondered if the problems were experienced with all nine provinces as well as the National Department. Dr Thulare noted that SAMA supported the content of the National Health Act, but felt that the implementation process was crucial and needed to be viewed in context. Stakeholders needed ‘a buy-in". The process should not be ‘top down’ only and needed to include a ‘bottom-up’ component as well.
Dr Selebano noted that SAMA had worked well with many provinces, especially given most junior doctors were provincially based. Certain situations remained problematic. SAMA was concerned that Scarce Skills was ending in 2006 and perhaps needed to be implemented again. The Department needed to resolve the soft issues and remuneration problems and adopt a holistic approach with a clear retention strategy. The problem extended to all members of the medical profession such as nurses and physiotherapists. Practitioners were not only leaving the public sector, but the profession as a whole. Dr Setsubi felt that there had been some limitations in their interaction with some provinces due to management not communicating adequately.
Dr Selebano added that SAMA should see the positive aspects of the Act, but the Certificate of Need (Section 36), had created problems and may have accelerated doctors leaving the profession. Other ways and means were needed to provide incentives for doctors to work in rural areas
Ms R Mashigo (ANC) asked what SAMA was doing proactively to assist in the output of black doctors from previously disadvantaged universities. Dr Selebano responded that most black doctors graduated from Medunsa University. There were complaints of a ‘revolving door’ policy at the established urban universities.
Dr Setsubi saw the need to build confidence and counter the effects of past history. He acknowledged SAMA’s responsibility in helping to bring about changes, as the doctors and medical school deans were SAMA members. He felt it was encouraging to have the Committee listen to them and would value more meetings with the Portfolio Committee and stakeholders. Dr Thulare added that SAMA needed to encourage transformation in medical schools.
Ms B Ngcobo (ANC) asked how far the WMA process was. Dr Thulare responded that most African countries had no resources and were not represented at forums. SAMA and the WMA initiative aimed to strengthen medical associations and ensure the whole continent became organised. Seven African countries had attended the meeting concerning an association for the continent held this year.
Ms Ngcobo wondered if there was a way to reduce the high fees and taxes paid by the doctors. Dr Luthuli added that fees for continuing education were exorbitant. It seemed that people were making money out of the training. As a doctor herself, she understood how prohibitive the costs were. In addition, general practitioners in private practice worked seven days a week, and had to employ locums at high cost while attending training. Dr Thulare responded that SAMA had requested a meeting with the Health and Finance Ministries to discuss ways that government could assist public sector doctors.
Ms Ngcobo enquired to what extent SAMA worked with traditional health practitioners in both urban and rural areas. Dr Thulare noted that SAMA published a book ‘Bridging the Gap’ and had collaborated with biomedical and traditional medical practitioners. SAMA worked from the premise of the patient as the centre of the equation and many South Africans consulted traditional healers. An addendum to the booklet was in production and would be published within six weeks.
Ms Ngcobo asked what role SAMA played in crises such as the incident at the Mahatma Ghandi Hospital. Dr Thulare admitted that SAMA had not been active in responding to that crisis and, as the body representing the medical profession, needed to improve that in the future. Dr Setsubi added that when the Red Cross had to close after hour’s service due to a financial crisis, SAMA members in private practice offered to provide back up. Co-ordination had been poor and so the initiative had not been sustained. Ms Pillay noted that SAMA had tried to initiate a team of doctors to help
after the Tsunami disaster. The Department had said that doctors must first deal with national problems. SAMA then submitted a list of doctors willing to volunteer for national and international crises to the Department.
Dr Luthuli referred to the issue of ‘limitation of rights’ in medical care when resources were limited. She noted that South Africans did not expect their rights to be curtailed and wondered what SAMA was doing to educate the public in this regard.
Ms Ngcobo enquired whether doctors from previously disadvantaged communities were joining SAMA. Dr Thulare responded that since the new formulation of SAMA in 1998, many previously advantaged doctors had become disillusioned and left the organisation. The new SAMA leadership was attempting to attract these senior experienced doctors back to play a mentoring role in the transformation process.
Ms Mashigo asked if SAMA had discussed with the Department ways in which private doctors could assist in alleviating shortages at public hospitals. Dr Selebano agreed that private doctors did often have spare capacity, but the Department had an inflexible attitude regarding working hours. Experienced private doctors were not given the recognition and appropriate remuneration. Dr Thulare noted that there were private doctors willing to assist and emphasised the need for PPIs, which were currently unstructured. SAMA had had talks with the Department but nothing had materialised.
Mr Njikelana asked SAMA how effective the Health Professionals Act had been in restructuring the various disciplinary measures to monitor doctors and ensure the maintenance of ethical practices. Ms Pillay explained that the Health Care Council had a backlog of complaints. SAMA had assisted the process through a peer revue process held in branches and 90 percent of cases were resolved at that level. She added that SAMA had asked for observer status on the Undesirable Business Practice Committee but were refused. The Committee dealt with issues such as perverse incentives and ‘kick-backs’.
Mr Njikelana asked SAMA to comment on corporate institutions employing doctors. Dr Thulare made it clear that SAMA did not support corporate entities such as Netcare employing doctors, as the profit motive overtook the concerns of patient care. They were supportive of non-profit organisations employing doctors.
Mr Njikelana enquired about SAMA’s relationship with other professional bodies. Dr Thulare explained that SAMA was co-ordinating the South African Health Care Professional Alliance, a forum of all health professionals with the goal of improving the care of patients. A constitution had already been written, and the forum would soon be launched.
The Chairperson requested the Parliamentary Officer note all the issues raised by SAMA for further discussion by the Committee.
The meeting was adjourned.
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