Exodus of SA doctors looms
2008-06-09 10:07
The government's decision to regulate private health care prices has sparked a wave of protest from doctors and the medical industry. In a weeklong special report News24 investigates the issues and talks to all stakeholders.
In the first installment, our partner Health24 looks at the issue from the perspective of the doctor.
More than a quarter of SA-registered doctors have already left the country. And two out of every three of those who haven't, will consider leaving if tariffs are fixed by legislation.
A battle is looming on the health care front, with the minister of health on the one side, and the private medical industry on the other. The core of the conflict: the high price of private medical care, which places quality medical care beyond the reach of many average South Africans.
So what's been happening?
On June 2, Minister of Health Manto Tshabalala-Msimang introduced a draft Bill in Parliament, proposing that medical fees and tariffs and hospital costs in the private health care industry be regulated according to set fee structures.
The industry reacted with horror. Dr Kgosi Letlape, chair of the South African Medical Association (SAMA), called the proposed fixing of tariffs "unethical and diabolical" in a press release. He went on to say that this legislation would not "improve access and quality in health care. The solution lies in devoting adequate financing and proper management of resources."
The Netcare Group of Hospitals issued similar press releases in which Mark Bishop, head of funder relations at Netcare, spoke of Netcare's "continued sense of discomfort at the appointment of a non-independent facilitator, and the fact that neither the facilitator nor the Department of Health accepts any liability should the results of the regulations cause damages to any organisation or individual."
He goes on to say that if the National Health Reference Price Listing (NHRPL) tariffs were implemented as the ceiling price that may be charged by hospitals, it would result in these institutions losing 15 cents for every rand of revenue currently received.
What the stats say
Only between 7 and 8% of South Africans have medical cover, leaving the remaining 92 to 93% in the care of overburdened State hospitals, which are faced with staff shortages and budget cuts.
On the other hand, around 12 000 of 44 000 SA-registered doctors have already left the country for greener foreign pastures - a trend which SAMA says will increase if the government regulates fees in the private health care industry.
In an interview with Health24, Dr Letlape made the point that the vast majority of South Africans who enter the medical profession do so because they want to work within South Africa, for its citizens.
However, if working conditions, poor salaries and lack of equipment make it impossible to fulfill this aim, they will either leave the profession, or find an environment, either foreign or local, in which they can render the service for which they were trained.
A SAMA survey has indicated that two-thirds of SA doctors would consider leaving if the new Bill were implemented.
The government, while expressing concern at this skills flight, gives little acknowledgement to the fact that poor working conditions, salaries and lack of equipment in state institutions have hastened this process: the health minister has intimated that 25 000 health professionals (including nurses) are working abroad and has in the past announced plans to lure them back - none of which seemed to have succeeded, or indeed stemmed the still-continuing exodus.
This battle between the government and the private health care industry is not a new battle by any means. It has a historical precedent reflected by the following issues that have hit the headlines in post-1994 South Africa:
The differences between the NHRPL pricing structures, according to which the medical schemes pay their members' claims, and the SAMA rates, the pricing guidelines according to which private doctors bill their clients.
The exodus of South-African trained doctors to foreign countries where they have always been in high demand, often because of the good training provided by South African universities, funded by local taxpayers. Hence the instituting of a year of community service in order to get some local benefit for government investment in training these students.
The historical - and growing - differences in the level of health care in the private and public health care systems.
Growing regulatory legislation of the medical schemes industry, aimed at both increasing access to private medical care, and prescribing minimum protocols with regards to care. This has led to a shake-up of the whole schemes industry.
The high level of medical inflation - for the last few years significantly above the general inflation rate. This has resulted in private health care being beyond the means of the vast majority of South Africans, and has also placed huge pressure on an already overloaded state health care system.
The main concerns
With this proposed Bill, the government aims to improve both affordability of and access to private health care for the South African public.
Statistics provided in recent years by Discovery Health indicate that the poorest of SA citizens spend 10% of their income on private health care - often because of a lack of access to state health care, or because of emergencies, or a lack of transport to state facilities.
"Over the past years, the private health sector has been unable to increase access and also appears to be unable to contain cost escalations," the health minister said in the National Assembly during debate on her budget vote on June 6 2008.
She continued to say that "this process should bring some transparency into the process of tariff setting in the private health care sector and assist us to contain costs.
The intention of this Bill is to secure the sustainability of the private health sector in our country and not to destroy it as has been suggested in some quarters."
The private health care industry, which boasts several world-renowned specialists in their field, provides health care of a very high quality; sufficiently so, that health tourism has taken off in a big way.
Because of high demand for their services from both foreigners and locals, private doctors are able to charge fees far in excess of the NHRPL rates - and still be booked up months in advance.
Private hospitals also provide a level of care comparable to international care facilities of high standing.
Commentators differ on whether the new Bill would help or harm the private health care industry. It boils down to the right of the average citizen to have access to decent medical care, versus the right of the private sector to provide exceptional medical care, while being run as a profit-making business, dictated by market forces beyond the reach of legislation.
The intentions
Critics of the proposed Bill, which include several medical schemes such as South Africa's biggest open scheme, Discovery Health, fear that it may be counterproductive.
In a press release, Discovery Health said it "shares the minister's concern about the rising costs of health care and how this affects affordability for consumers".
However, it continued, "we believe that this form of regulation is not the most appropriate way to lower health care costs, and may well lead to distortions in the market and other negative unintended consequences".
Janine Louw, principal officer of the Naspers Medical Scheme, does believe that there could be some benefits to consumers as a result of the proposed legislation.
"Already, as a result of these proposed measures, certain costs, such as those of anaesthetic gases, have been cut. This can only benefit medical scheme members. It's a small start, but a start nevertheless. We are in favour of measures that would cut costs for our members - obviously within reason."
So where to now?
It remains to be seen whether legislation can exercise any control over market forces: if there is a need for private health care, and people willing and able to pay for it, should this be meddled with by the State?
Many commentators have expressed concern about the condition of the State health care system. The lack of funding, staff shortages, and lack of equipment, stand in stark contrast to the conditions found in the private health care industry.
"What we ultimately aim and hope for is one health system of which we can all be proud," says Dr Letlape. No one would dispute this statement, but how this is to be achieved remains to be resolved.
And while this squabbling is carrying on between the different parties, more and more health professionals are packing their bags and leaving our shores. And more local doctors are trying to deal with increasingly impossible workloads, while patients lie unattended in wards for hours.