Days after the Council for Medical Schemes in South Africa announced it had ordered a forensic investigation into its registrar, Monwabisi Gantsho, for allegedly soliciting a R3m kickback, an earlier report has come to light raising further questions about his conduct.Dr Gantso heads the agency charged with overseeing the R110bn medical schemes industry. In November 2012, the council’s acting chairman Trevor Bailey instructed law firm Bell Dewar to investigate a series of allegations made by senior staff against the registrar. The law firm’s report, according to Business Day, concluded that the registrar:
• Ignored recommendations made by a council task team for the appointment of independent curators to three different medical schemes — Bonitas, Sizwe and Medshield — and had instead appointed curators "with whom he appear(ed) to have a relationship";
• Delayed an investigation into troubled medical scheme Medshield "without justification";
• Refused to approve the merger of Nampak Medical Scheme and Discovery Health Medical Scheme for "no justifiable reason";
• Appointed staff without following due process; and
• Put pressure on a junior staff member to reveal confidential minutes of meetings of the medicine pricing committee.
The article provides further report on the follow up actions according to Business Day.
Public-Private Mix
November 2001
Richard Strouse, Barbara Carlson, John Hall, Center for Studying Health System Change, Washington, DC Peter Cunningham, Mathematica Policy Research, Inc. Princeton, NJ
In this report, the authors describe site selection, sample design, instrumentation and survey preparation, data collection methods, response rates, and sample weights. The Community Tracking Study (CTS) addresses two broad questions that are important to public and private health decision makers:
1. How is the health system changing? How are hospitals, health plans, physicians, safety net providers, and other provider groups restructuring, and what key forces are driving organizational change?
2. How do these changes affect people? How are insurance coverage, access to care, use of services, health care costs, and perceived quality of health care changing over time?
The African Commission on Human and People’s Rights calls on States Parties to the African Charter to take appropriate policy, institutional and legislative measures to ensure respect, protection, promotion and realization of economic, social and cultural rights, in particular the right to health and education and to fulfil their obligations on this. The Commission calls on States Parties to adopt legislative and policy frameworks regulating private actors in social service delivery and ensure that their involvement is in conformity with regional and international human rights standards. States Parties are invited to ensure that the involvement of private actors in the provision of social services is a result of a participatory policy formulation process and continues to be subject to democratic scrutiny and to the human rights principles of transparency and participation. The Commission considers carefully the risks for the realization of economic, social and cultural rights of public-private partnerships and ensure that any potential arrangements for public-private partnerships are in accordance with their substantive, procedural and operational human rights obligations, and do not violate the norms and principles of the rights contained in the African Charter; and to ensure through regular impact assessments that the involvement of private actors in the provision of health services and education does not create systemic adverse impacts on human rights. Further States Parties are to ensure access to an effective remedy for violations of the right to health and education or other human rights violations by private actors involved in the provision of health and education services. The Commission reminds private actors of their responsibility to respect economic and social rights, particularly the right to health and education and to refrain from infringing on human rights as they engage in the provision of these services.
The question of why privatisation and commercialisation of public services is taking place is a hotly contested one. Neoliberal analysts have argued that privatisation occurs because states fail: state officials are rent-seeking, inefficient, unaccountable, inflexible and unimaginative. Privatisation is seen as a rational and pro-poor policy choice, obvious to anyone willing to look at the track record of public versus private sector delivery: The authors here argue, by contrast, that the privatisation of public services has not happened because it has been inspired by some renewed sense of cultural enthusiasm for the market, but rather that it has become a necessity imposed on the state by economic circumstances: reduced public borrowing; cuts in state spending; liberalisation; and the opening up of new economic fields for intensified capital accumulation. Not surprisingly, some of the biggest boosters of privatisation are the private companies themselves, which have spent considerable time and effort trying to secure new market opportunities. They have actively sought contracts around the world, and consultancy firms, such as PriceWaterhouseCoopers and KPMG, have been actively promoting privatisation efforts and lobbying for the expansion and acceleration of the General Agreement on Trade and Services (GATS).
The funding of healthcare in South Africa is a highly contentious issue, involving a variety of stakeholders. Royal Philips released the South Africa results of the first edition of its Future Health Index (FHI) in July 2016. The FHI is an extensive international study which explores how countries around the world are positioned to meet long-term global health challenges through integration of health systems and adoption of connected care technologies. The report revealed that cost is a significant barrier to healthcare in South Africa and that HCPs and patients indicate improving access to healthcare services as a core priority for local government. Health status indicators in South Africa as a whole are reported to be worse than that in other upper middle income countries. Privately insured people though have outcomes comparable to best in world. However, this comes at a high cost. People in South Africa who cannot afford private medical insurance have some of the worst outcomes in terms of healthcare. The report identifies that approximately 40% of total healthcare funds in South Africa flow via public sector financing intermediaries (primarily the national, provincial and local Departments of Health), while 60% flow via private intermediaries.
The role for the private sector in health remains subject to much debate, especially within the context of achieving universal health coverage. This roundtable discussion offered perspectives from a range of stakeholders – a health funder, a representative from an implementing organisation, a national-level policy-maker, and an expert working in a large multi-national company – on what the future may hold for the private sector in health. The health funder argued that the discussion about the future role of the private sector has been bogged down in language. He argued for a ‘both/and’ approach rather than an ‘either/or’ when it comes to talking about health service provision in low- and middle-income countries. An implementer of health insurance in sub-Saharan Africa examined the comparative roles of public sector actors, private sector actors and funding agencies, suggesting that they must work together to mobilize domestic resources to fund and deliver health services in the longer term. Thirdly, a special advisor working in the federal government of Nigeria noted that the private sector plays a significant role in funding and delivering health services there, and that the government must engage the private sector or be left behind. Finally, a representative from a multi-national pharmaceutical corporation gave an overview of global shifts that are creating opportunities for the private sector in health markets. No community member views were provided.
Health minister Dr Manto Tshabalala-Msimang speaking at the Board of Healthcare Funders' annual conference stated that the private health sector has seen an uncontrolled cost spiral since the 1980s and that it has become increasingly unaffordable for South Africans to belong to medical schemes. She identified the most important cost drivers as private hospitals, specialists and administrative costs.
In a recent meeting with private health care providers and insurers, Health Mininster Dr Tshabalala-Msimang criticised private providers for placing a large burden on health consumers, with out-of-pocket expenditures pushing patients further and further into poverty. She emphasised that a national health system cares for all and urged private providers to work with government to secure a decent national health system.
The South Africa Minister of Health, Dr Manto Tshabalala-Msimang held separate follow-up meetings with representatives of the private hospital industry and medical schemes in Cape Town to discuss the challenge of increasing private health care costs. The Minister welcomed the efforts that have been made by some of the private hospital groups to adjust the tariff increases for 2008 towards the CPIX. However, there were concerns from schemes that adjustments announced have not translated to any savings that can be passed on to the consumer. The schemes reported on the efforts that have been made to reduce non-health costs in the medical schemes.
South Africa’s health minister Aaron Motsoaledi has argued that consolidation of the private health care market has created a situation where the three largest private health care providers now dictate, not negotiate, prices to medical schemes. As listed companies, these providers aim to maximise profits, which, he argues, means they have little concern for affordable care. Cost escalation and overprovision in South Africa’s private sector is also seen as a consequence of the fact that regulation of the private sector has focused more on medical schemes and less on providers. Lawyers say that the imbalance in legislation puts medical schemes in a weaker position when negotiating with hospitals. One economist points to utilisation increases by 3% every year, which he argues are being driven by specialists and private hospitals that have profit sharing arrangements, with a high probability of collusion between the hospital groups because of the way in which they share profits and incentives. Specialists, on the other hand, blame the high costs of new drugs as responsible for price increases in private care. They say the pharmaceutical industry is hiking its prices significantly, presenting a barrier to care in both the private and public sectors, where even drugs coming off patent remain costly.