White Paper on transformation of the health system in South Africa: hearings

Meeting report

HEALTH PORTFOLIO COMMITTEE
16 March 1998
WHITE PAPER ON TRANSFORMATION OF THE HEALTH SYSTEM IN SOUTH AFRICA:
HEARINGS

Documents available:
Chamber of Mines submission
Concerned Medical Schemes Group & RAMS members
The White Paper on Transformation of the Health System in South Africa

List of organisations who presented submissions on the White Paper on Transformation of the Health System in South Africa:
Actuarial Society of SA Health Care
Association of Retired Persons & Pensioners
COSATU
Democratic Nursing Organisation of South Africa
Freedom of Commercial Speech Trust
Life Offices Association of South Africa
Medical Association of South Africa
Medical Research Council: UDW
NACOSA (Western Cape)
NPPHC Network
Pharmaceutical Manufacturers' Association of South Africa
Prior Institute
Old Mutual Health Care
Representative Association of Medical Schemes
Women and Human Rights Project
Gender Advocacy Programme

Summary:
This meeting was the first in a series of five meetings arranged for 16-20 March to garner public comment on the White Paper on Transformation of the National Health System. During the four hour meeting, presentations were made by three parties: the Department of Health, the Chamber of Mines of South Africa, and the Concerned Medical Schemes Group. Each presentation was followed by questions from the MPs directed to the presenters.

The presentation by the Department of Health discussed the history of health sector reform in South Africa since the late 1980s and highlighted key points and overarching themes of the White Paper. The presentations by the Chamber of Mines and the Concerned Medical Schemes Group expressed overall support for the vision articulated in the White Paper of a more equitable and effective health system, but expressed concern about specific provisions of the Paper which may affect the private sector.
Most of the 16 MPs present were actively involved in the discussions that followed each presentation.

The minutes below briefly summarize each presentation and record the questions asked by the MPs and the responses offered by the presenters.

Minutes
The meeting was opened at 9:30 a.m. by Dr. S.A. Nkomo. Dr. Nkomo welcomed all individuals present and stated that all present were in agreement on the importance of transforming the health system in South Africa.

Presentation 1: Department of Health
The Department of Health presented an overview of the history and content of the White Paper on Transformation of the Heath System in South Africa. None of the many provisions and proposals in the White Paper are new. All the provisions and proposals have been advanced by one or more groups in the past decade in the course of a national search for a common vision to transform South Africa’s health system. In the White Paper, the government has attempted to undertake a holistic rethink of the South African health sector in order to correct the numerous and serious structural defects of the sector.

The current government began the process of formulating national health policy by appointing twelve technical committees to review different elements of the health care system. The recommendations of these committees informed and influenced the development of the first draft of the White Paper. [Note: no Green Paper was developed.] After publishing the first draft of the White Paper, the Department of Health received approximately fifty substantive responses from private sector and civil society organizations. These responses were reviewed and incorporated into the second draft of the White Paper. About eighty substantive responses were submitted to the government after this draft was released. These submissions were considered in drafting the final version of the White Paper, published in April 1997. The hearings this week have been called to garner input on this final version. The presentation continued with an overview of key points and overarching themes in the White Paper.

Questions and Discussion
Mr. M. Ellis of the DP asked how the submissions received at these hearings would be used. Would the White Paper be rewritten to incorporate the views expressed? Mr. Ellis commented that these hearings should have been held before the consideration of the three health bills passed last year. He expressed the hope that the results of these proceedings would impact substantially on the debate on the health bills to be considered in the 1998 session of Parliament.

Dr. Nkomo answered that the White Paper has been finalized and will not be altered to reflect views expressed in these hearings. He said that these hearing should not be considered an idle exercise, however. Rather, the hearings afford interested parties an opportunity to offer comments that can guide the forthcoming translation of the principles and implementation strategies articulated in the White Paper into legislation.

Mr. Ellis asked about the status of the National Health Bill and whether any of the input received during these hearings would inform the drafting of this bill. The Department of Health responded that the Bill will likely be tabled during the 1998 session. Nine high-ranking colleagues from the Department of Health would attend all the hearings, listen carefully, and incorporate appropriate input into their contributions to the development of the bill.

Citing a desire to use time efficiently, Dr. Nkomo stated that all MPs with questions should ask them at this time. Dr. ___ would then respond to all the questions at once.

Mrs. A. Tambo of the ANC expressed concern that the needs of the elderly and their caregivers were not adequately addressed in either the White Paper or the RDP. She noted that the UK has a system that provides home-based support for the elderly, particularly those suffering from Alzheimer’s disease, and for the people who care for the elderly. She asked if South Africa could employ a similar approach.

Dr. R Rabinowitz of the IFP made several points:
On the issue of HIV/AIDS, she stated that policy should be changed to reflect South Africa’s need to move beyond awareness raising to a more proactive approach emphasizing behavior change. She suggested that HIV/AIDS needs to be treated more as a public health crisis than as a human rights issue. She recommended introducing legislation that makes it a crime not to divulge one’s serostatus to a sexual partner if one is HIV positive.
On the issue of collecting health data, she suggested that the information could have multiple uses in addition to informing top policymakers and administrators. She suggested that the database be used to prevent illegal aliens from using South African health care facilities.
On the issue of community health committees (CHCs), she observed that CHCs are often not legitimate representatives of the public, but rather politicized institutions. She suggested careful review of this concept and the implementation strategy devised to operationalize it.
Last, she indicated that community health workers (CHWs) are not mentioned in the White Paper. She expressed the belief that CHWs play crucial roles in addressing a wide range of community health needs, including problems arising from HIV/AIDS, needs of the elderly, and others. She noted that NGOs could in some cases provide these CHWs, but that NGOs needed clearly stated government policy supporting placement of CHWs in order to source funds to support the CHWs.

Dr. K.R. Meshoe of the ACDP asked how the shift in emphasis from tertiary to primary care in the health care system would be advanced. He also asked what role tertiary institutions would play in the new health system.

Mrs. M.A. Njobe of the ANC asked what plans the Department of Health had for making the medical field, and particularly doctors, more demographically representative of the nation. She noted that this was particularly important because black doctors are more likely to practice in the rural areas, which currently are severely underserved. She commented that the Demographic Health Survey planned by the Department was very important and urged them to carry through with the plans. She noted that psychiatric service provision has been neglected in South Africa, and she expressed concern that psychiatric care would continue to be marginalized if it was made the responsibility of the provinces.

Dr. E.E. Jassat of the ANC noted that considering the critical shortfall of medical professionals in the country, efforts were needed to prevent graduates from South African medical institutions from leaving South Africa. He also suggested that reforms were needed that would more readily allow qualified doctors from other countries to practice medicine in South Africa, particularly in the rural areas.

Mrs. J. Chalmers of the ANC expressed concern about the confusion in provincial administrations about the division of responsibilities between the health and welfare departments, particularly vis-a-vis psychological care for the mentally ill. She noted that there were many clinical psychologists in the country who spoke Afrikaans or English, but few who spoke African languages. She suggested that efforts be made to increase the number of clinical psychologists who speak one or more African languages. She asked about the current status of the demarcation of districts by the Department of Health, asking also when they would be finalized. She expressed concern that in her province, the Eastern Cape, the funds of one sector were siphoned off to pay for the overruns of another sector.

Mr. M. Ellis of the DP strongly supported the approach of allowing health care institutions to retain a proportion of the payment they receive. He asked what proportion the collecting institutions would receive and how the proportion returned to the central government would be used. He asked what relationship was envisioned between the current medical schemes and the proposed national health insurance program. He asked how the national health insurance program would be financed, expressing concern that it might be funded out of a health tax paid by the employees, the employers, or both.

An unidentified member of the ANC asked how traditional healers would be incorporated into the health care system.

Dr. Ntsaluba of the Department of Health responded to several of the queries. He stated that increasing the number of black doctors is a high priority for the Department. To that end, the Department does not seek to close Medunsa. Instead, the Department is working to determine what problems Medunsa faces so that they may be addressed.

He noted that the problem of high expenditure in tertiary institutions will be relieved to an extent through the decentralization process, but indicated that other measures were necessary.

He noted that Department is currently exploring models for community-based care, not as a means of shifting responsibility for the sick away from the health system but rather as a way of supplementing the system and maximizing the effectiveness of the investment of South Africa’s limited resources for health.

Finally, he indicated that the Department is reviewing ways of incorporating traditional healers more fully into the national health system.

Dr. Nkomo indicated that more time would be set aside later in the week for the Department to address questions that were not answered today.

Presentation 2: Chamber of Mines of South Africa
Dr. MAC La Grange, Health Advisor to the Chamber of Mines, presented the submission of the Chamber. She invited members of the committee to visit health facilities operated by South African mining companies, stating that some observers have compared them to the U.S. health system. She stated that the major issue which South Africa must contend with in transforming its health system is finding the ways to achieve primary health coverage for all without jeopardizing the high quality care provided by the existing health care system.

Dr. La Grange indicated that the submission of the Chamber would focus on the parts of the White Paper that affect the Chamber directly. She pledged that the Chamber was willing to cooperate within the guidelines of the White Paper. She expressed hope that public/private sector relationships around health would take the form of voluntary cooperation rather than regulation. However, several provisions of the White Paper suggest that the government is seeking to extend its control over the private sector. Also, she observed that the White Paper does not fully acknowledge the important role that occupational health providers play in the overall health system.

As a provider of health services to its employees, the mining industry should be exempted from contributing to any national health insurance program that may be developed. The Chamber suggests that the Department of Health open a more broadly consultative process as it develops a national health insurance scheme.

A representative of Anglo-American spoke briefly after Dr. LaGrange finished, echoing several of her sentiments. He added that Anglo was concerned about the trend towards reregulation and would like to see evidence regarding the increased costs brought by deregulation which are cited as grounds for the reregulation initiatives.

Dr. Nkomo suggested that instead of allowing questions, the third presentation would be made; then MPs could ask questions of both sets of presenters.

Presentation 3: Concerned Medical Schemes Group

Mr. A Gore of the Concerned Medical Schemes Group stated that the private sector generally and medical schemes in particular have an important role to play in promoting the nation’s health. He expressed concern that the White Paper indicates that medical schemes will be required to operate within a restrictive regulatory framework. The Group believes that this kind of approach will lead to a decline in the number of people who are covered by private schemes.

He strongly refuted the claim that deregulation of medical schemes has been detrimental, indicating that the number of persons enrolled had risen and that costs had been controlled. The group believes that rates will rise substantially if the government forces medical schemes to accept any person regardless of health. However, the Group does agree with the principle that once a person has joined a scheme, her/his rates should not be based on her/his health.

Questions and Discussion Based On Presentations 2 and 3

Dr. Rabinowitz of the IFP stated that her party agreed with most of the concerns raised by the Chamber of Mines. She asked how the Chamber would suggest that mistrust of the private sector by the government be reduced.

Mrs. Tambo of the ANC asked the difference between the Chamber of Mines and the mining houses. She asked if the Chamber contributed in any way to the payment of workers’ health costs. She asked about the other social policies of the Chamber, particularly in education.

Mr. Ellis of the DP asked if the presenters felt that the private sector had been adequately represented in the White Paper formulation process. He also asked what type of relationship the presenters foresaw between the medical schemes and the national health insurance program.

An unidentified ANC member asked how the Chamber of Mines intends to address the needs of people with disabilities. She expressed concern over the mining houses’ practice of ‘dumping’ patients no longer able to work into the public sector facilities. She asked what criteria currently are used to determine eligibility for medical schemes. She asked how the private sector would benefit from the White Paper and the transformation it envisions.

Another unidentified ANC member expressed concern that the private sector is not cooperating with the transformation process. At this point Mr. Ellis of the DP interrupted to object to use of question time for the purpose of making political points. The Chair chided him for interrupting and eventually restored order. The ANC member asserted that the Chamber needs to provide better care for miners who have been disabled. She asked what plans had been made to deal with the pensions of people who die of HIV/AIDS.

Response by the Chamber of Mines

Dr. La Grange and the representative from Anglo-American explained that the Chamber of Mines is an association of the mining houses of South Africa. The Chamber does not provide health services itself: this is undertaken by each mining house. They noted that the mining houses provide a wide range of health services to employees, including tertiary health care if necessary. They recognized that the issue of ‘dumping’ is a real problem and requires review. The mining houses are interested in comprehensive care packages, but find them very expensive. Most mining houses do not currently offer coverage to dependents of employees. This is being reviewed. The Anglo representative believes that the best way to overcome public-private mistrust is by working together as much as possible and by arranging forums like these that allow for exchange and dialogue.

Response by the Concerned Group of Medical Schemes

The Group believe that medical schemes face three key issues:
What to do with today’s old?
What to do with tomorrow’s sick?
What to do about the millions of South Africans whose health care is not funded?

The group does not oppose all reregulation, but believes that the community rating system is too simplistic and will cause three problems:
1) Consumers will not see value for money and will be less willing to pay
2) Costs will rise as more vulnerable people move into the system
3) Young people may opt out of the system, so increasing the burden on the middle-aged and the old.

Representatives from the Group expressed a desire for closer involvement with government in policy formulation. They expressed optimism about the prospects of public/private sector cooperation in the future.

After thanking all participants for their contributions, Dr. Nkomo closed the meeting at 1:45 p.m.