An organisation representing South African doctors working in the private sector has expressed unhappiness over perceived stonewalling from the government with regards to the Covid-19 treatment effort.

In a letter to members seen by Daily Maverick, the South African Private Practitioners Forum (SAPPF) says its repeated attempts to negotiate with the national Department of Health in “offering our support in combating this pandemic” have not met with a satisfactory response.

At the heart of the issue is the treatment of “state-responsibility patients” for Covid-19 in private medical facilities – and what the doctors will be paid.

Department of Health spokesperson Popo Maja told Daily Maverick he could not give comment on the issue as he had not seen the relevant figures.

But according to the SAPPF, the Department of Health has offered a per diem rate of R2,493 per patient to specialists managing Covid-19 patients in private hospitals.

This fee is standard regardless of whether the patients are in ICU or High Care, and must be split between a team of doctors if a patient requires more than one specialist within a 24-hour period.

The SAPPF says it undertook “very extensive work” to calculate a per diem fee which amounted to the following:

• ICU: R5,572 per patient per day;
• High Care: R2,428 per patient per day; and
• General ward: R1,203 per patient per day.

In its letter to members, the SAPPF says the counter-offer of R2,493 presented to them during a meeting with the department’s Dr Nicholas Crisp is considered “non-negotiable”.

The SAPPF’s concerns centre on the distribution of money between the various specialists who are likely to be required to treat acute Covid-19 patients. A patient who requires mechanical ventilation, for instance, needs a team including an intensivist (an ICU doctor) and an anaesthetist.

Beyond the question of payment, another thorny issue is that of legal indemnity for private-sector doctors volunteering to treat Covid-19.

“In order to utilise all available capacity, many doctors will be asked to work outside their scope of practice or area of specialisation,” the SAPPF states.

“We have requested from the minister some type of blanket indemnity from prosecution for medical negligence, should claims for medical negligence arise as a consequence of working outside one’s scope of practice in treating a Covid-19 patient. No such indemnity has been offered.”

It is evident from the SAPPF’s memo to members, and from other private-sector communications seen by Daily Maverick, that private-sector representatives fear that whatever arrangements are reached during the Covid-19 pandemic will form the basis for NHI logistics in the near future.

This issue has arisen worldwide as doctors from all specialisations have been drafted to treat Covid-19. In several US states, doctors are now shielded from lawsuits over Covid-19 medical treatment. The UK’s Medical Protection Society has called on the British government to introduce emergency laws to protect doctors from criminal and regulatory investigation during the Covid-19 crisis.

The SAPPF says that a legal team arranged through Business for SA (B4SA) is currently working on the matter of South African indemnity for all healthcare workers.

Virtually from the onset of the Covid-19 pandemic, South Africa’s medical resources in the private sector have been presented as vitally important. For months, government officials and private-sector representatives have been referring to a public-private partnership as key to handling the pandemic.

“Covid-19 will make the collaboration [between the public and private healthcare sector] much closer,” Health Minister Zweli Mkhize told a World Health Organisation media briefing in late April.

The government’s own modelling on the likely spread of Covid-19 has consistently counted private-sector ICU beds as an important element of the state’s capacity.

Yet what is clear from the current beef between the SAPFF and the Department of Health is that the details of this private-public collaboration are still uncertain – even as state hospitals in the Western Cape are already straining under the Covid-19 burden.

The SAPPF paints the government as being uncooperative in the face of good-faith attempts by private-sector doctors to volunteer their services at the risk of their own health.

“This lack of engagement suggests that the intention is to exclude the private sector, as far as possible, from an integrated national response, except when absolutely necessary,” the body states.

“In cases of necessity where the public sector is overwhelmed and help is required from the private sector, it appears that the relationship will be a one-sided take it or leave it affair, with no negotiation and no consideration given to the realities of costs experienced by private practitioners or facilities.”

Government health officials have a very different take on the dispute.

Senior health figures, speaking off-record to Daily Maverick, strongly implied that the payment conflict arose from the clash of worlds between the private and public sector, with the private sector accused of not being transparent about their costs and providing estimates based on a “for-profit” universe.

It was also denied that the government has been unwilling to come to the table: extensive and intricate negotiations have already taken place, it is claimed.

Complicating the matter is the overhanging spectre of the National Health Insurance (NHI).

It is evident from the SAPPF’s memo to members, and from other private-sector communications seen by Daily Maverick, that private-sector representatives fear that whatever arrangements are reached during the Covid-19 pandemic will form the basis for NHI logistics in the near future.

Some doctors have suggested that whatever Covid-19 per diem fee is agreed on now will remain frozen as the NHI fees for specialists.

The SAPPF, meanwhile, states: “It may be that politicians see this crisis as an opportunity to fast-track NHI rather than serve the country during a period of crisis”.

There has been no indication thus far that this is government’s intention, though numerous observers have commented that the handling of the crisis provides an interesting window into what a future NHI could look like.

During the same WHO media briefing where Health Minister Mkhize referred to the crisis as bringing the collaboration between public and private health systems “much closer”, Mkhize was asked whether the Covid-19 response might accelerate South Africa’s transition to the NHI.

Mkhize’s response, paraphrased in a WHO report on the briefing, was that progress with the NHI “would have to wait until the coronavirus was dealt with, in order to attempt to align the interests of both public and private players”.

Just how difficult aligning those interests is likely to be is evident from the current dispute in the middle of a health emergency.

But arguably the matter of greatest concern currently is the ongoing failure to reach a clear agreement on the logistics of public-private resource-sharing – after 62 days of a lockdown intended to prepare the health system. DM