In this second part of a 2-part series Anso Thom, reporting for the Healthe News Service asks whether the issues around cheaper drugs, certificates of need, social health insurance, mean that government has made sudden and major shifts in health policy?
Reforms introduced by the revised Medical Schemes Act have already prepared the way for some form of national health insurance. Essentially, Social Health Insurance aims to ensure all people in formal employment have access to contributory health cover.
There are three areas that still need clarification from the perspective of future health insurance users.
These are; what proportion of income would go towards health insurance and will employers be forced to pay a percentage?; Will the state be the sole provider of health services or will it be done in partnership with the private sector?; Who will administer the fund - the State, the private sector (turning it into a big medical aid, but not replacing current medical aids) or a parastatal?
Currently there are 7,025-million people who are beneficiaries of medical schemes (16,2% of a population of 43,325 million). At the fullest extent a further 8,127-million could potentially become beneficiaries.
Lowest income groups and those without an income are expected to remain in the publicly funded system. This amounts to 28,173-million people.
Government is clear that over time, contributions to some form of health care cover should become mandatory for all those with the ability to pay. It is expected that the mandates will be phased in over time, beginning with high-income earners and specific categories of employers.
The mandates could then be broadened with the establishment of a state-sponsored scheme to meet the needs of lower-income people who will not be able to afford conventional medical schemes.
The current favoured proposal is that those on Social Health Insurance will use designated facilities (public-private facilities) and should they opt to go elsewhere, pay the difference.
Despite reforms introduced by the Medical Schemes Act, it is still possible for some open schemes to design and market themselves in such a way that they attract younger and healthier people. This leaves other schemes with older and less healthy people. Legislation aims to address this via a Risk Equalization Fund.
In its simplest form, the fund receives contributions from those schemes with a younger age and better health profile and pays amounts to schemes with an older age and poorer health profile.
The legislation will also address the huge tax subsidies afforded to those on medical schemes.
Estimates for 2002 are that tax expenditure subsidies to medical schemes amounted to R7,8-billion, which represents over R1 000 per beneficiary per annum.
This is more than the public sector spends per head on delivering healthcare. It is viewed as inequitable that the subsidy to the private sector is greater than that to each person in the public sector. These tax subsidies could be rerouted to pay for those not able to afford health care.
Although a component of the soon-to-be introduced National Health Bill, it is critical that the Certificate of Need is introduced at the same time as Social Health Insurance.
Devised as an instrument to redistribute (mostly newly graduated) private medical doctors, pharmacists, health establishments and technology services to less-well-served areas the certificate has proved controversial.
In an attempt to cool tempers, the Minister of Health, Manto Tshabalala-Msimang told a parliamentary briefing this week that the regulations would not target doctors but health establishments (hospitals and medical centres), pharmacists and technology centers.
Rather than removing established doctors, the Certificate of Need will seek limit to the number of private doctors in a demarcated area. But it will take some time before it comes into effect.
Those affected will be given two years to register once the regulations have been legislated, a process that could take time.