Claims against the Gauteng Health Department for alleged negligence in hospitals sit at R4.3 billion. According to the Democratic Alliance's provincial health guru, Jack Bloom, this year the department paid R22.2 million to Thato Mokheti for negligence during an operation on his neck that resulted in him losing the use of an arm. Cleopus Souls got R15 million after losing his left leg after negligent treatment, and five payments from R700,000 to over R14 million were paid for causing babies brain damage at birth. Instead of fixing the system, the department reportedly wants to go after the lawyers pursuing the claims.
The public healthcare system is often hampered by staff shortages, insufficient infrastructure, equipment and medicines, poor management... the list goes on. It's where the large majority of South Africans seek care and is at the frontline of transformation. So it makes sense for the public system to get the most attention.
But as the deadline for late submissions to the Competition Commission's market inquiry in the private healthcare sector expired this week, serious questions are being asked about how the private health sector functions. The inquiry, which after analysis of the submissions will hold public hearings from May to July 2015, could have wide implications for the almost nine million people belonging to medical aid schemes, others who use pay out-of-pocket to use the system, and many more South Africans.
The basis for the inquiry is simple: there are concerns the private healthcare industry isn't working for consumers. In the 10 years to 2010, the increase in spending at private hospitals was over double the inflation rate, with no regulation on the cost of services and no transparency on how prices are set. By the end of October, 59 parties had made submissions to the inquiry and another 10 were given until this week to make late submissions. Given the information overload, the inquiry will focus on work related to costs, affordability, access, innovation and quality, as well as competition and sustainability in the sector, resource requirements to consumers accessing healthcare, and the availability of data and information to consumers. It's a mouthful. With serious implications.
Take E, one of a number alphabet-named patients in public interest law group Section27's submission exemplifying the problems. E is a member of Bonitas Medical Fund and HIV positive. With the development of new drugs, he changed antiretrovirals a number of times and a related side effect, lipodystrophy, led to fatty growths on his neck. He couldn't sleep, felt back pain and had extreme headaches. His doctor said the growth needed to be removed, but Bonitas denied his application. A year later the lipodystrophy caused loss of consciousness, and the doctor again recommended surgery but Bonitas denied once more, claiming it was a cosmetic procedure. Eventually, E used what savings he had to pay for the surgery.
Later, Section27 helped him recover the money from Bonitas because it should have been covered in full as a prescribed minimum benefit (PMB).
The Medical Schemes Act sets minimums that every scheme must cover. To register, a medical scheme must provide members with cover for a list of PMBs. The scheme “must pay in full, without co-payment or the use of deductibles” for diagnosis, treatment and care. The medical scheme business is huge, with 42% of total health spending being related to such schemes, more economically significant than in other OECD countries. You'd think they meet their minimum requirements, but the Council for Medical Schemes tasked with monitoring delivery on PMBs has noted glaring non-compliance. Most complaints relate to schemes failing to honour the most basic obligations; it's unlikely many people even know, however, of the failure or that they can complain.
Take M, a single mother from Somerset West, diagnosed three years ago with metastatic breast cancer. That means the cancer has spread to other parts of her body, with symptoms including severe pain, swelling, brittle bones, persistent headaches, vision problems and behavioural changes. Her medical aid, however, denied payment for Herceptin, a crucial drug for treating breast cancer. When she went to the media, the medical scheme decided to pay. The treatment of breast cancer is also on the minimum benefit list, meaning the scheme had to pay regardless of the plan she was on.
Instead, while dealing with life-threatening stage-four cancer, M had to battle for medication she should have been receiving as part of her medical aid.
There are others too. R struggles to pay for her chemotherapy and radiation treatment because she's on her husband's medical scheme that doesn't offer treatment in her area, so she travels hundreds of kilometres, and the scheme only pays for some rather than all of the treatments despite it being a minimum benefit. There's 65-year-old P, who needs her second new hip. Fracture of the hip is a PMB, but her Transmed medical aid would only pay R41,000 for the prosthesis – she was quoted R51,000 – and the elderly woman would have to pay for the R110,000 surgery herself.
Ensuring medical schemes meet the minimum requirements of certain diagnosis, care and treatment costs is one of the issues the inquiry will look at, one which causes emotional and financial distress among people who should be covered but are sometimes neglected.
Section27's submission begins by outlining the constitutional obligations the private system has towards meeting the right to health. The group argues that the law envisages a unified system comprising both public and private healthcare, obliging all parties to promote the right to health. “Simply put, people do not relinquish their constitutional rights when they buy healthcare services through the private healthcare sector. Nor should their choice to access healthcare service in the private sector make them participants in a separate health system, subject to separate constitutional standards, artificially separated from those applicable to the public health system,” says Section27.
This stance could mean the inquiry goes beyond just evaluating competition and price and moves the system towards increased regulatory frameworks and obligations on private healthcare providers to put the right to health before profits.
Companies are set to fight against such moves as well as anything that may interrupt their run of profits. Already the inquiry has been held up when Netcare went to court earlier this year to prevent KPMG from working for the commission as the company had worked for Netcare in the past. The inquiry said Netcare's sought relief could severely jeopardise its work. The court judgement cited Netcare's stance on the commission: it is adverse to its interests. The company's CEO Richard Friedland's position was clear: if you don't like the costs of the private system, use public services.
Essentially, the company appeared against probing into its sector at any cost and the legal action was meant to interrupt the inquiry's work. An entitlement runs through its comments: use the public system, or pay and don't ask questions.
Section27's submission to the inquiry questions this position. It argues the country needs a unified healthcare system where the private sector would be under regulations to meet its obligations at affordable prices, as well as the rights of citizens, and ultimately work alongside the public sector to deliver decent healthcare services. DM
Read more:
- Health inquiry website.
Photo: A woman walks past the head office of Netcare Limited in Sandton, north of Johannesburg, South Africa, 20 August 2008. The company operates 68 hospitals and 82 retail and hospital pharmacies. The subsidiary Netcare 911 provides a private emergency service with over nine million members and a fleet of over 500 contracted and owned response vehicle ambulances, three helicopters and three fixed-wing air ambulances. EPA/JON HRUSA