CPC/Qualicare and IPAF’s Submission on the National Health Amendment Bill Nov. 2019
CPC/Qualicare in the Western Cape is an important member of the IPAF Foundation of SA.
The Independent Provider Association Foundation (IPAF) of South Africa is the umbrella body for the majority of the Independent Provider Association (IPAs) in the country. It comprises of:
- CPC/Qualicare, KZNDHC and a number of other IPA groups that are also represented by the South African Medical Contracted Community (SAMCC);
- The South African Medical and Dental Practitioners Provider Network (SP Net)
- the Gauteng MCC (GMCC) and;
- The Association of South African IPAs (ASAIPA);
Each of these organisations consist of Independent Primary Healthcare Providers. These providers have agreed to submit to Peer profiling, Peer review and Peer Mentoring and are presently contracted through the IPA Foundation to certain medical schemes and medical schemes administrators to provide medical services to their contracted members (patients).
This process is committed to ensuring quality cost effective outcomes and is aimed at providing continuous medical education (CME) and up-skilling of doctors.
Although many of the doctors are in solo practice, the IPAs are organized to serve as a “Virtual Home” to these practitioners. As a collective they can provide Best Care, extended care outside office hours and healthcare coverage, by mutual agreement between practitioners.
IPAF and CPC/Qualicare support the need and principle of Universal Healthcare. Apart from servicing the Private Sector, the IPA doctors have been providing healthcare to the Public Sector and uninsured patients over many years. Our doctors have delivered cash discounts, all-in consultations and medication for a fixed tariff and often delivered pro-bono care to patients in the community who can’t afford even discounted costs. The extent of this service has never been measured or even estimated but is roughly computed to be worth over R 1billion per year. It is throughout the country and even in the remote areas. Primary care has been pivotal to care in the country and General and Family Practitioners have stood up to deliver this care given the resource constraints.
It has always been our vision to be part of Healthcare Restructure, redesign and the need to give access to all our people in SA.
An inventory of the currently available resources in this country needs to be compiled in order to co- ordinate all resources both in the public and private sectors, all physical resources, personal both medical and administrative and management. Existing IT systems should be identified and employed where they are optimally used. The non-functioning resources need to be repaired and reformed into functional units.
Pervading all these requires an attitudinal change from all sectors, State and Private with a new a willingness to participate and co-operate and where services are given to our patients, a caring serving willingness that is palpable.
1. THE PROBLEMS WITH THE PROPOSED MODEL
We are gratified to note that there is mention made of Universal Health Coverage in the NHI Bill 2019 in that the Duties of the Fund include that the Fund must: “take all reasonably necessary steps to achieve the objective of this Act and the attainment of universal health coverage”.
List of concerns (expressed by our Constituencies):
- - It is difficult to understand and comment on a bill where its full application and its actual eventual cost to taxpayers is unclear at this stage.
- - No explanatory memorandum or draft regulations were provided with the draft Bill.
- - No indication is given as to the financial viability of the NHI Fund.
- - How the Fund will be funded is left to regulations covering budget, fees, fund reserves, and fund investment of moneys that will be determined by the Department of Health on their own at some future stage.
- - The extent to which services will be covered, including receiving life-saving care within sufficient time is not clear. The Benefits Advisory Committee will determine this on their own at a future uncertain date. This should not be done in isolation. Public and Private expertise needs to be assessed in an unbiased way using the only criteria quality, ability and competence.
- - The limitation of potentially applicable constitutional rights such as freedom of trade, occupation and profession, access to courts, human dignity, life, and privacy are not mentioned.
- - The MOST IMPORTANT matters are left to regulation at some future uncertain date.
- Further items requiring clarity are:
- Legal relationships between Fund and health establishments, service providers or suppliers; Payment mechanisms to purchase personal health care services from certified, accredited and contracted service providers, health establishments or suppliers;
- Information to be provided to the Fund for the development and maintenance of the National Health Information Repository and Data System, and the format;
- Clinical information and diagnostic codes to be submitted and used;
- Participation of the Fund in the National Health Information Repository and Data System, including the Health Payment Registration System;
- Registration of users;
- Accreditation of, and reporting by, service providers, health establishments or suppliers serving users;
- Relationship between public and private health establishments, and the optional contracting in of private health care providers;
- Relationship between the Fund and medical insurance schemes and other private health insurance schemes;
- Complaints and appeals against the Fund, and monitoring and evaluation of the performance of the Fund;
- All practices and procedures to be followed by service providers or suppliers in relation to the Fund;
- Defining the scope, benefits and nature of health service benefits and programmes and the manner in, and extent to, which they must be funded; and
- Payment of health care providers;
- - The proposed NHI Bill 2019 will apparently be implemented over three phases which makes its application highly uncertain.
2. COMMENTS ON THE PROPOSED MODEL
- - The Private Healthcare Sector is to be subjected to more restrictive regulation and eventually the services that it is allowed to deliver may be severely restricted. RESPECT AND AWARENESS OF WHAT IS ALREADY AVAILABLE MUST NOT BE WASTED.
- - On the other side the Fund is set up with regulation that is only to be determined at some future uncertain date and time.
- - The Fund is not subject to legislation as, for instance, the Competitions Act.
- - The NHI Bill is drafted very wide in terms of funding, delivery, contracting and governance while at the same time being vague and uncertain containing only a small amount of practical implementable detail.
- - Income and expenditure will be determined and managed in terms of the Public Finance Management Act and audited by the Auditor General. This immediately suggests qualified reports by the Auditor General on health departments in South Africa. We cannot go through any fraudulent or greedy exploits; there has to be zero tolerance for any dishonestly or incompetence.
- - The funding will be appropriated funds from Parliament.
- - Section 52 of the Bill gives the Minister of Health the power to make a list of regulations covering almost everything mentioned in the Bill.
- - There are few limits to the Minister’s powers, and he/she can pass regulations without public comment if he/she considers it necessary. There needs to be some form of measuring of responsibility, competence and the outcomes of decisions. Ongoing monitoring is needed to identify flaws before they cause damage. This will help the minister to share the huge burden of responsibility.
- - Benefits, pricing, registering, accreditation and contracting will be done by appointed committees taking away the decision from patients and practitioners.
- - Service Providers dealing with the Fund will be told where, what and how to deliver their services as well as how much to charge. This may amount to being dictated to but not employed by the State.
COMMENTS ON THE NEED FOR A STRONG COMPETENT FOUNDATION:
We implore the Minister to concentrate on the most vital components of health which is water and sanitation and housing. People must have an environment that is hygienic and not toxic.
These must be regarded as a priority and whatever is built needs to be of a high quality that is sustainable and with proper maintenance will endure the challenges of nature.
We are suggesting that UHC and NHI this is one of a number of parallel processes that should be started, all looking at a foundation that will last and able to be built on.
Other parallel processes need identifying and then implementing. In principle these include physical resources, human resources, medical, nursing and allied professionals. Other resources to be included are all managerial and administrative functions which must be based on honesty and integrity and underpinned by a robust financial management system.
3. THE UNIVERSAL HEALTH COVERAGE SOLUTION FOR SOUTH AFRICA
It is our opinion that the following components are essential to achieve Universal Health Coverage in South Africa:
1. Family medicine:
We propose an approach to attaining Universal Healthcare Coverage as discussed and fully set out in the WHO document named Conceptual and strategic approach to family practice: towards Universal Health Coverage through family practice.
2. An intelligent digital healthcare system:
We propose a system that is compatible with the various platforms in current use by Practitioners in SA.
3. A multi-disciplinary Community Oriented Primary Care (COPC) approach:
We propose a COPC approach after consultation with the Family Medicine Departments in SA.
4. Entry Point:
We support the proposal that the Primary Care will be the entry point into the NHI.
5. Periodic Consultative Process
We also advocate the need for periodic consultative process with the NHI executives and the Health Professionals.
6. Patient-Centric Approach
We strongly advocate for a Patient-Centric Approach with the Patients central to healthcare decisions.
7. Training and support for care givers and nurse practitioners
We foresee a huge strain on existing resources and that many services can be rendered by personnel who have limited training and skills. If these people are supported by highly trained Family/Primary Care Physicians, they will be able to serve with confidence. They all need to have a caring attitude and can be used to provide education of hygiene and personal health and care, they can assist in first aid, family planning and home-based care.
FINALLY, WE COMMIT TO CONTRIBUTING OUR SUPPORT AND SERVICES TO THE DEVELOPMENT AND MAINTENANCE OF UNIVERSAL HEALTHCARE DELIVERY.
Dr Tony Behrman and QC Team