THE SOUTH AFRICAN MEDICAL ASSOCIATION (SAMA) Representative Professional Association for Doctors in South Africa

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THE SOUTH AFRICAN MEDICAL ASSOCIATION (SAMA)
Representative Professional Association for
Doctors in South Africa
Presentation to Parliamentary Portfolio
Committee on Health 6 September 2005

• Presented by-
• Dr Aquina Thulare
• Secretary-General SA Medical Association

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Our Team

• Dr Aquina Thulare (SG/CEO)
• Dr Barney Selebano (Corporate Affairs)
• Dr M. Stoltz (Chair, W. Cape)
• Dr Oscar Setsubi (W. Cape Member)
• Ms Maliga Pillay (Legal)

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Purpose of Presentation

• THE ROLE OF SAMA
• ITS FUNCTIONS AND ACTIVITIES
• OPERATIONAL PROCESSES
• CHALLENGES

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Who is SAMA?

• Professional Association Sect 21
• Voluntary membership
• 70 public and private doctors
• Est. May 1998 MASA PDG/NAMDA
• Total Unification April 1999
• WMA member
• Trade Union affiliated to COSATU

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Mission

• To empower doctors to bring health to the nation

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Objectives

• Represent the doctors with authority and
  credibility
• Promote integrity and image of profession
• Develop medical leadership and skills
• Provide doctors with knowledge
• Promote medical education, research and academic
  excellence
• Encourage involvement in health promotion and
  education
• Influence the health care environment - promote
  improvements to health reform, policy and
  legislation
• Act as the change agent in the health care
  transformation process

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Activities

• SAMA believes doctors can positively influence
  medical practice by
• Anticipating and influencing health policy
  changes in the interest of the profession and the
  public
• Promoting access to affordable, quality health
  care

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SAMA STRUCTURE AND PROCESS
SAMA NATIONAL COUNCIL
Health Policy
Education, Science Technology
Committee for Public Sector Doctors
Human Rights, Law Ethics
Private Practice Committees (GPs and Specialists)
Surgical Disciplines
Consulting Disciplines
56 Speciality Groups
21 SAMA Branch
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Core competencies of SAMA

• Private medical practice
• Private practice policy, Develop diagnostic and
  procedure coding systems, Represent profession at
  CMS, BHF, RAF etc
• Public sector health matters and human resources
• Labour advice, Collective Agreements,
  Disciplinary hearings, CCMA, Bargaining Councils,
  Grievances
• Health legislation, regulation and policies,
  human rights, medical law and ethics
• Legislation, advice, drafts guidelines,
  stakeholder liaison, clinical protocols,
  co-ordinate standing committees

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Education Publishing

• Professional development and training
• FPD est. 1997 - registered private institution
  for higher education
• Publishing house
• HMPG, 25 000 subscribers, SAMJ, CME, etc.

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Value Proposition

• Through its organizational structure and core
  competencies, SAMA is positioned to
• Represent the medical profession with integrity
  and credibility on interaction with government,
  the legislature and stakeholders
• Influence the shaping of the healthcare
  environment to meet the needs and expectations of
  government and the SA population, at large, by
  promoting improvements to health reform, policy
  and regulation

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• SAMA supports and endorses the DoHs vision for
  a health system for the future to
• move towards a coherent, unified health system
  offering financial protection for all the
  population, in accessing a nationally affordable
  package of health care, at the time of need
• and
• Away from a segmented and inequitable health
  system that burdens the country with unaffordable
  costs

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OPPORTUNITIES

• LEGISLATIVE FRAMEWORK
• AND RELATED
• DEVELOPMENTS

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National Health Plan

• Published in 1994
• Public document
• Policy principles
• Access
• Affordability
• Appropriateness
• Regulatory principles
• Cost of care
• Facilities
• National Health System
• Private sector

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Constitutional Framework

• Bill of Rights
• Everyone has the right to have access to
• Health care services
• Social security, including, if they are unable to
  support themselves and their dependants,
  appropriate social assistance
• The state must take reasonable legislative steps
  within available resources to achieve a
  progressive realisation of rights
• No one may be refused emergency medical treatment
• Limitation of Rights

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Legislative Framework

• Regulation of medical schemes
• Regulation of benefits
• Regulation of MCOs and administrators
• PMBs

Medical Schemes Act
Council for Medical Schemes
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Legislative Framework

• Professional Boards
• Training
• Code of conduct
• Continued professional development
• Protecting the public and guiding the profession

Medical Schemes Act
Health Professions Act
Health Professions Council
Council for Medical Schemes
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Legislative Framework

• Medicines Control Council
• Pricing of medicines (SEP)
• Dispensing regulations

Medicine and Related Substances Act
Medical Schemes Act
Health Professions Act
Council for Medical Schemes
Health Professions Council
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Legislative Framework

• Certificate of Need
• National Health Reference Price List
• Health Councils

National Health Act
Medicine and Related Substances Act
Medical Schemes Act
Health Professions Act
Health Professions Council
Council for Medical Schemes
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Challenges

• Definitions and Content
• Legislations and Regulations
• Implementation

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Basic Health Care

• Access to health care services Basic healthcare
  package to be defined
• Basic health care ? Primary health care

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Components of Basic health care
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Stakeholders to decide..

• Which portions of the secondary, tertiary and
  quaternary care will form part of the definition
  of the basic healthcare package
• This will impact on SHI and basket of benefits in
  Basic Benefit Package
• Low Income Medical Scheme
• Prescribed Minimum Benefits

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National Health Act

• Provides uniformity in health services across the
  nation
• Eradicates racial disparity in health care
  delivery
• SAMA supports the objectives, in general
• Certificate of Need (Sect 36)

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Section 36 of NHA - CoN

• A person may not
• establish, construct, modify or acquire a health
  establishment or health agency
• increase the number of beds in, or acquire
  prescribed health technology at, a health
  establishment or health agency
• provide prescribed health services or
• continue to operate a health establishment or
  health agency after the expiration of 24 months
  from the date this Act took effect,
• without being in possession of a certificate of
  need.

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Main concerns on the CoN

• Criteria for regulations not clearly defined
• Violates free market principles of supply and
  demand - S22 of SA Constitution
• Family life affected and Economic uncertainty
• Patients rights to choose a doctor
• Maximum duration is only 20 years
• CoN process internationally was not successful
  (need unique RSA solutions)

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SAMA position on CoN

• We accept the principle of a CoN to address
  needs
• It is critical to identity healthcare needs
• Interactive discussion with the DoH and
  healthcare stakeholders are imperative
• Complementary processes-
• To incentivise health care professionals to
  practise in underserved and/or remote areas
• Comprehensive Human Resource Plan

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SAMA suggests

• Meeting between DoH and stakeholders
• Understanding of Need concept to be analysed
• The public sector issues to be formally debated
• Incentives for retention of healthcare
  professional in SA - accurate economic and
  actuarial data required

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Public sector issues

• Shortage of medical personnel
• Poor working conditions
• Work overload
• Insufficient career-pathing
• Problems with Supervision
• Salaries scarce skills allowance, rural
  allowance, special incentives, RWOPS
• Taxation of Public Sector Doctors - HPCSA, SAMA
  and MPS fees, and CPD fees for attending courses,
  congresses and seminars (major deterrent)

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Reasons for leaving the public sector SAMA
Survey 2003
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The Charter of the Public and Private Health
Sectors of The Republic of South Africa(the
Charter) released for public comment on 11
July 2005
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Draft Health Charter

• SAMA supports
• The need for health care system to be transformed
  at various levels
• The notion of patient-centredness
• SAMA believes that health and medical
  professionals have a pivotal role to play in this
  regard

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Key Transformation Areas

• Access to Health Services
• Equity in Health Services
• Quality of Health Services
• Black-Economic Empowerment

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Access, Equity Quality

• Critical success factors
• Development of tools such as clinical guidelines
  and formularies
• Retention of health care professionals in South
  Africa
• Properly structured and sustainable Public
  Private Partnerships and Initiatives
• Strengthening of Public Sector

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Objective of PPPs and PPIs

• Should support the objectives of improving access
  to health care by
• Addressing the needs of patients in underserved
  and rural areas
• Leveraging off spare capacity, where it exists,
  in the private sector
• Incentivising health professionals to pursue
  careers in underserved areas by improving working
  conditions and the development of innovative
  business models

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PPP / PPI and CoN

• PPPs could well contribute to meeting some of
  the objectives of the proposed Certificate of
  Need through
• Improving access to, and distribution of,
  healthcare to all patients
• Addressing the needs of underserved and rural
  areas through interactive engagement with the DoH
• Cost containment within the public sector through
  PPPs with the private sector e.g. utilization of
  health technologies
• Provision of highly specialized services to the
  public sector. This could also strengthen
  training capacity at all levels within the public
  sector
• Retaining health professionals in underserved
  areas by improving working conditions

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PPPs / PPIs Successes

• PPPs have already been successfully implemented
  between the SA Society of Ophthalmology and
  Government in the provision of health services
  for the removal of cataracts
• Similar developments between other Specialist
  Groups affiliated to SAMA are indeed possible.

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BEE Challenges in the Charter

• To meet BEE equity objectives for the medical
  profession will require a different approach,
  because
• Output of qualified black doctors including
  specialists in historically advantaged
  institutions-inadequate
• Transformation of the human resources within the
  professions is almost totally dependent upon the
  degree of transformation at the various
  universities, both at under- and post graduate
  level.
• Need to increase number of institutions geared
  towards increasing numbers of black healthcare
  professionals

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BEE Challenges

• Interactive engagement process between DoH,
  HPCSA, Medical Universities, other relevant
  Academic Institutions as well as SAMA and other
  professional Associations is required.

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OTHER HEALTH POLICYISSUES
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Health Professions Act

• There is improved communication with MDB and
  HPCSA
• Transgression of ethical rules and policies
• Challenges
• Ownership of practices by non-medical
• Employment of doctors by corporates (except for
  emergency units)
• Undesirable Business Practices Committee to deal
  with applications

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Medicines and Related Substance Act

• Dispensing Regulations
• Constitutional Court (regrettable)
• Unanswered questions -
• Regulations not yet amended
• Licences renewal in 3 years
• Ongoing annual fees of R800.00
• Discursive argumentation Funders and
  pharmaceutical companies act as watchdog
  ultra vires?

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Medicines and Related Substances Act

• Pricing Regulations
• Intention of affordable medicines supported
• Presentation made to Pricing Committee
• Need for Private practice sustainability
• Ongoing problems
• Uncertainty since Constitutional Court case
  pending
• Threats by funders to charge per pricing
  regulation which are invalid

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Other Areas of Divergence

• Schedule 5 Medicines- Mental Health Act versus
  Medicines and Related Substances Act
• HP Act versus Medical Schemes Act versus
  Competition Act (DSPs)

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National Health Reference Price List (NHRPL)

• NHA mandates MoH to determine a NRPL
• Medical Schemes may determine their benefits and
• Service providers may determine their fees but
• These fees are not mandatory
• List does not apply only to health professionals
  (but also to funders)

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Questions iro NHRPL..

• Should it remain with CMS?
• Does DoH have capacity?
• Need for a separate Statutory body?
• Can it be negotiated at a forum similar to a
  Bargaining Chamber ?

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Medical Schemes Act and ICD-10

• Came into effect 1998
• Challenges
• Exact patient benefits iro PMBs
• No formal process to update Chronic Disease List
• Standardized policy on DSPs
• Mandatory ICD-10 codes / Confidentiality
• Section 53 Suspension of payments

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Social Health Insurance

• SHI takes REF process one step further
• Health tax introduced
• Commence 2008 ?
• Concerns on SHI
• How many additional patients will benefit ?
• (7 million to 10 million)
• Basic healthcare package to be determined
• To be administered through current medical scheme
  infrastructure (high costs, capacity)
• Interaction between public and private sector are
  vital
• Poor will get poorer (no rebates)
• Funding (actuarial) model versus service model

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Risk Equalisation Fund

• REF Essentially, schemes with a poorer risk
  profile to be subsidised by others
• Shadow process commenced 2005
• No exchange of monies
• Fully implemented in 2006/7

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In short

• Objectives of all legislation are commendable in
  general
• But
• Clinical autonomy
• Sanctity of doctor/patient relationship
• Fee for service at point of delivery
• Two tiered health system

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Bill of Rights Access
COIDA
National Health Charter
Low Income Medical Scheme
Health Professions Act
Prescribed Minimum Benefits
National Health Act
Medicines Act
Certificate of Need
ICD-10
Social Health Insurance
Designated Service Providers
National Health Reference Price List
Risk Equalisation Fund
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Way Forward

• Holistic versus Piece-meal approach
• Focus on fundamentals
• Impact of legislation on patients and the
  profession
• Basic Healthcare Package
• Integrated Human Resource Plan
• Balance Quality Service Delivery and Funding
  Model
• Consistent and unified approach

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Access Equity Quality Affordability
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Basic Healthcare Package Human Resources Service
Delivery Funding
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CONCLUSION

• SAMA subscribes to principles of participatory,
  deliberative and constructive terms of engagement
• SAMA is committed to finding a workable and
  sustainable framework of solutions for healthcare
  delivery in SA.

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Thank you