Serious shortage of doctors
A “Marshall Plan” is needed to increase the number of doctors if the country’s healthcare system was to remain sustainable, said executive government and stakeholder relations at Medi-Clinic, Dr Nkaki Matlala.
Speaking as part of a panel discussion at the Hospital Association of South Africa (HASA) annual conference, Matlala said a national plan would require political will from all sides. “Whether from the public or private healthcare sector, we have come to realise that we are all serving the same population and our ideas need to converge on this issue,” he added.
With just six doctors per 10 000 people versus a global average of 15, SA was well below its peers. About half of all doctors registered with the Health Professions Council of SA (HPCSA) are working outside SA.
Noted Jonathan Lowick, Group executive: Business Development & International at Life Healthcare, “Over the past twenty years, there has been a rapid increase in demand for healthcare in SA, but there hasn’t been a shift in supply of doctors,”
Regulatory and bureaucratic forces limited the number of doctors to meet demand. As a result, doctors have migrated out of the public sector into the private sector and also overseas.
Lowick said draconian restrictions on registering foreign doctors should be lifted and plans for more doctors and nurses trained put in place. He said just 1 409 doctors were trained in 2014 in eight state-run medical colleges, a small increase from the 1 229 trained in 2001. “We should really look critically at our regulations and what they are doing to restrict training of doctors,“ he added. “Until then we are just tinkering with the system, and not addressing the fundamental problems.”
Regulations prohibiting corporates from employing doctors should also be reviewed and were not global best practice.
“When institutions can’t employ doctors, the result is expensive, uncoordinated care,” said Lowick. “It also complicates the development of centres of excellence and inhibits innovation.”
Chairman of JMH, Dr Ramesh Bhoola, said there was a severe shortage of training posts in the public sector for doctors who wanted to specialise. There were also limited opportunities and supporting infrastructure for doctors to conduct research.
“Local universities could collaborate with overseas universities and doctors could do their clinical work in SA,” said Bhoola. “In this way we could easily increase the number of medical graduates.”
He added that private sector hospitals had capacity to train doctors, but establishing private medical colleges would need buy in from a range of institutions.
Struggling to contain costs of care
Private healthcare market inquiry opportunity to understand private hospital claims.
Rising expenditure on healthcare is not a peculiarly South African challenge, as spending on healthcare is growing globally.
HASA Chairperson Melanie DA Costa said, “Around the world governments are grappling with the question of how to contain healthcare expenditure. It is systemic issue around the world.”
“The trend in increased demand for healthcare comes from aging populations; lifestyle diseases; increases in income and education levels; as well as consumerism, which is not unique to any country. Obesity, for instance, is a challenge right around the world that leads to illness and eventually places pressure on the healthcare system,” she added.
In addition, as people’s incomes rose globally, they demanded more and better healthcare services. “When income goes up, people not only consume more health care, they actually increase the percentage of their income they spend on health care,” added Da Costa. “As a result of rising incomes people are also living longer resulting in a rising burden of chronic disease that requires more healthcare expenditure.”
In South Africa, factors such as the deteriorating risk profile of the average medical scheme member had severely impacted costs. Increased expenditure on hospitals was driven by growth in the number of medical scheme beneficiaries (15.4%); utilisation (25.6%); general CPI inflation (50.8%). Only 8.2% could be attributed to real hospital price inflation.
Over ten years, medical scheme members spent billions on non-healthcare costs, such as R45 billion that went towards building schemes’ solvency rates because of regulations.
Da Costa emphasised that medical scheme membership had increased by 2.25 million lives and that research shows that about 80% of people living in households earning above R250 000/year had medical aid in South Africa. But she pointed out that about 5% of the country’s population paid 70% of personal income tax so there were significant affordability constraints.
She said the public debate had stagnated over the past few years around price of providers, but of the 68 submissions to the market inquiry, most had focused on health policy. “Few people know that private institutions cannot train healthcare professionals, whereas in the rest of the world, this is not even a case for debate. If we trained more doctors and nurses, there would be a greater supply of professionals and a concomitant reduction in the pay existing professionals could demand. This is a policy matter that could help make inroads into the rising expenditure on healthcare,” added Da Costa.
“HASA believes that the healthcare market inquiry offers an opportunity for an independent and impartial process into the functioning of the national health market,” she said, adding, “It could also point the way to several healthcare policy adjustments that will result in a stronger healthcare system.”
She urged medical schemes to improve their risk profile by encouraging young and healthy members to join. This would lower the scheme risk profile and facilitate lower medical scheme contributions.
Help needed to deliver universal healthcare
Minister of Health, Dr Aaron Motsoaledi told delegates that the question on the minds of health ministers across the globe was how to provide access of good quality to all citizens. “We are finally finished with the White Paper on National Health Insurance (NHI) and are just waiting for the next available opportunity to present to cabinet,” he said. He anticipated that there would be questions about whether SA can afford universal healthcare.
“The question is rather can we afford not to?” he added. “There is no option other than to provide healthcare to all citizens because not doing so is not only unjust, it does not make economic or political sense.”
He said accurate forecasting of how much NHI would cost is extremely difficult. “Ten years ago we needed R10 000 to treat one patient with HIV,” he explained. “Today we need only R1 000 per patient.”
He said SA’s health system could leapfrog to the level of developed countries if it used technology, behaviour change and new business models. These changes would need to be rolled out at speed, on a mass scale and would need to be affordable to be sustainable. He added that government would work with the private sector as it was doing in Gauteng hospitals.
“We will utilise both public and private sector to provide healthcare for the citizens of this country.” Motsoaledi explained that the government’s school health programme found that of 280 000 school children screened, one third had hearing, speech or eyesight problems. “We need optometrists, speech and hearing therapists - the only way to get help for these kids is to go to the private sector.”
Referring to the Council of Medical Scheme’s annual report he said the cost of healthcare was ever escalating, but in analysing what was driving these costs, it was very clearl it was diseases classified as Non Communicable Diseases (NCDs). He added that the answer lay not in building more hospitals but getting to the root of health problems. For example, a National Health Commission would be set up comprising public and private representatives to tackle SA’s quadruple burden of disease including the HIV/AIDS epidemic alongside a high burden of TB; high maternal and child mortality; high levels of violence and injuries; and a growing burden of NCDs, such as hypertension and diabetes.
“We must put laws, regulations and policies that help us reduce quadruple the burden of diseases to make sure that the costs (related to these) come down,” added Motsoaledi. He asked private sector healthcare providers to help the government meet the goals set out in the National Development Plan including increasing life expectancy to 70 years and ensuring an HIV-free generation under 20 years old by 2030.
The value of leveraging the skills of the private sector
Professor Hsiao of Harvard University argued that until now, government efforts had been aimed mostly at supporting public hospitals when more short-term solutions could be found if government leveraged the private hospitals, many of whom are members of the Hospitals Association of South Africa.
Hsiao said its members, with 37 000 acute hospital beds, 220 hospitals and 150 000 employees could use its knowledge, experience and innovation to help contribute to better quality healthcare, access to treatment, and efficiency if government and private hospitals found a way to work together.
“In the short run the challenge remains how to leverage the strengths of the private sector to strengthen the healthcare system of South Africa, while in the long run, it is about how to harmonise the public and private health sectors of South Africa.”
Hsiao is a renowned authority on national health care systems. He has provided analysis and consulting services to 30 countries within Europe, Africa, Asia and Australasia, and has served as an advisor to three United States Presidents, the United States Congress and other global health and economic organisations, such as the International Monetary Fund, World Bank and International Labour Organisation.
In his talk, Hsiao pointed out that the state could contract hospital management companies to transfer knowledge and operational systems to public hospitals and pointed to Singapore as an example. In addition, selected functions such as food and laundry, and the management of public hospitals or administration of social health insurance could also be outsourced, he said.
“From an international perspective, up to this point, the NHI pilot system has only tried to strengthen the delivery system in the public sector,” he added. “There needs to be more active piloting and trying out of alternatives.
“I liken the long-term aim of harmonising the healthcare system to an orchestra. One not only needs to include the various sections of an orchestra to create a whole, but also to teach them how to work together. In this sense, the public and private hospitals have different strengths that need to work together. On the one hand, the public hospitals offer universal access and are publicly funded, while on the other, private hospitals attract private investment and are targeted at those who are willing and able to pay. On the one hand, public hospitals are far more bureaucratic than the far more agile and dynamic private hospitals that are driven by market forces,” he said.
“In this type of environment, private hospitals are driven by competition and have to respond by appealing to what patients want and their willingness to pay as well as to be alert and innovate. This is not always the case with pubic hospitals,” said Hsiao.
Public hospitals can benefit from their use of managers from the private sector who have the competency because they have learned it, to manage hospitals and to learn from latest international knowledge and experience in managing hospitals. Globally the private sector offered a source of capital investment and services not provided by the public sector and was a source of knowledge and management skills for social health insurance plans and hospitals and health centres.
“This can be leveraged to the benefit of everyone,” said Hsiao. “If you unlock people’s imagination and technical know-how, you can develop highly specialised services at much less cost.
Responding to Professor Hsiao’s talk, the Chief Executive of HASA, Dumisani Bomela said that his organisation was committed to ongoing discussions with the Department of Health with a view to strengthening healthcare delivery.