MEDICAL CHRONICLE | May 2022

when they need it. Meanwhile, many privileged people are given treatment they don’t need, some potentially harmful. And even wealthy people who insure their health with medical schemes end up paying in for costs not covered,” Dr Crisp said.

“The bottom line is what we have is not working for us. SA needs a health system that ensures that all people have access to the health services they need, when and where they need them, without financial hardships. This is what universal health coverage means. National Health Insurance means that we pay for this public good in advance with no cost to us as patients at the point of care when we need health services.

NHI NOT NEW

“We’ve actually been trying to reform this healthcare system for a very long time, in fact we started in 1948 when Henry Gluckman was the Minister of Health he tried to implement the NHS, the same sort of form as the UK, and since then there have been more than 20 attempts to create a national health system in the country, both by the previous government and this government, but we’ve never managed to move beyond this.

Dr Crisp stressed the fact that there is room for improvement in both the public and private health sectors with a need for quality investment throughout the system. “To build a strong and reliable public health system, the implementation of NHI is supported by several parallel health system reforms and strengthening initiatives by using the six health systems building blocks described by the World Health Organization Framework, including leadership, financing, medical products and consumables, information technology, human resources for health, and service delivery.”

He further explained that the investment in public health sector quality improvement will continue through several integrated components to develop and improve the quality of services including the capacity of the health system to deliver service to communities. “The aim is to progressively build capacity and quality in both public and private sectors,” said Dr Crisp. “People believe the NHI will start on the first day of whatever, but that's not how it works. All these improvements will take time, hence the need for a staggered approach to accreditation to prevent collapsing of services while developing the quality. The point I’m making is that it’s a constant process and it happens on a journey, not an event on a particular day.”

STILL FIGURING IT OUT

Dr Crisp also admitted that they hadn’t worked out how to do everything yet. Referring to the NHI Pilot Districts as examples he said they had learned many lessons. “For instance, the GP contracting in my opinion, has been a disaster, we have learned how not to contract GPs into the NHI rather than how to do it. We do want to contract GPs, but the way in which it was done in the pilot was not useful at all and we didn’t get value for money.”

FUNDING NHI

“The bottom line is that in the end NHI is paid for by taxes, there’s no getting away from it, that’s how it works,” said Dr Crisp. “The question is how much of that money is already in the system, but funded through different streams, and where is it?

“If we take the 8.4% of GDP, half of that is already paid for in tax allocated through the Division of Revenue Act or the MediumTerm Expenditure Framework – depending on whether you’re looking at one year or three years – and it’s already spent in the public service. So that’s about R260bn.

“Then we have R34bn which is already in the tax system that is refunded to people who get private medical schemes. Now that money, without changing the tax regiments at all, could slowly but surely be shifted into the public purse to purchase services from the NHI Fund.

“Then we have the subsidies which the public sector pays to its employees to purchase private healthcare. Now we don’t have the exact figure here, but we know that it’s more than R50bn,” said Dr Crisp. “We also pay huge sums of money into the Compensation Fund for Occupational Disease and Injury (COIDA) and the Road Accident Fund (RAF) and the health services that are provided through those funds are not going to be duplicated, they are only paid for by those funds, but they are duplicative, and they are quite expensive to deliver. So, rerouting those funds is also something that was raised in the hearings and is quite possible.

“What is left is not R200bn, or whatever the media keeps reporting, it’s substantially less and we will slowly but surely work out the numbers. We have done various models and not everybody agrees on what the numbers are, and there may be some double counting of some of these numbers in the process. But it’s definitely under R100bn.

“The question then becomes how do we raise the remaining money?” Dr Crisp asked. One of the things he said was to not spend money in the first place. “We need to stop the fraud and corruption, the R11bn in the private sector that is stolen every year and the billions that are stolen in the public sector every year. We need to put control measures in place to not waste that money. We need to cut down on the cost of administration. We know that in the private sector the cost of administration of the many funds, and that includes the practitioners’ costs to support them, the way they react to selling their services costs between 12%-15% of everything that is spent by medical schemes,” Dr Crisp stressed.

“What we’re working towards is having healthcare free at the point of care. Where we’ve paid for everything upfront in our tax collection mechanism,” said Dr Crisp. “Getting there will take some time, but we need to start, we need to begin the journey, next year, this year, whenever the Bill gets through the parliamentary process. Then, these various implementations need to be phased in. Starting with the public service, starting with primary healthcare, and then as we go through the budget cycles and systematically changing the way in which medical schemes work, looking at capping various things, harmonising PMBs with the primary healthcare benefits in the public sector, etc, many of the things that were listed in the Health Market Inquiry.

“It is a progressive process over several years and not an event,” concluded Dr Crisp.

May the force be with all of us

Dear Reader

May the force be with all of us during the start of the 5th wave, amid the flooding in KZN, load shedding and violence at hospitals. The National Health Insurance Bill was recently in the news again when the Department of Health was called to respond to some of the criticisms raised by stakeholders at the parliamentary public hearings on the NHI Bill. Find out more in this news article. On the technology front, robotic-assisted knee and hip replacements have been established in Pretoria. A team of orthopaedic surgeons at Netcare Pretoria East Hospital are using a robotic surgical system to expand options in hip and knee replacements. SA pulls together in KZN rescue effort. The apocalyptic floods that have ravaged

KwaZulu-Natal have resulted in unspeakable loss, heartbreak, and displacement – the toll of which will be felt for a very long time. Netcare brings our attention to the considerable effort on the ground and phenomenal involvement of a large rescue community of citizens and healthcare professionals alike. The Healthcare Workers Care Network (HWCN) has found that 82% of the South African doctors, nurses and allied health professionals using its counselling services believe there is a stigma attached to healthcare workers asking for help with their own mental health.

CThose who take care of others are more likely to suffer in silence than to seek help for their own symptoms of anxiety, depression, stress, and burnout.

The HWCN network is a joint initiative of the South African Medical Association, the SA Depression and Anxiety Group, the SA Society of Psychiatrists, and the SA Society of Anaesthetists, supported by the Psychological Society of SA. We uncover their findings in this news article. With a significant rise in coronavirus infections across SA, all signs point to the country entering a fifth wave. Epidemiologists predicted the fifth wave would hit around winter, which is also associated with flu season. This raises the urgency for everyone to get their annual flu shot as soon as possible. Read more in news. One of the most significant concerns any healthcare practice faces is the possibility of fraud. Practitioners can become so focused on patient care that it is easy to neglect the proper management of financial and other risks. We expand on this in Limiting fraud in the healthcare practice. Dr Ilhaam Mohamed looks at the important aspect of quality of life in COPD. Over the last few years, there has been a continued global interest in pharmacological interventions, non-pharmacological measures and mental health programmes that may improve the quality of life in patients with COPD.

Need to earn more CPD points? Don’t miss Getting rid of actinic keratosis. This article is a summary of an article available on www.medicalacademic.co.za. Take the quiz online and earn your CPD point immediately. In Strategies to manage VTE, Prof James Ker introduces us to haemodynamically stable venous thromboembolism. In the next issue of Medical Chronicle, he will examine strategies to manage the condition.

All content in Medical Chronicle is sourced independently and under no circumstances should articles be considered promotional unless specified. Please note that all advertising is intended for healthcare professionals only.

NEWS

The NHI is a process, not an event ............. 1 Robotic-assisted knee, hip replacements in Pretoria............................................................ 4 SA pulls together in KZN rescue effort....6 Healthcare workers fear mental health stigma ....................................................................7 Flu vaccine vital ahead of 5th wave...........8 Acino committed to expansion and localisation.........................................................10

CLINICAL

WEBINAR ANNOUNCEMENTS

HIV in 2022: Paediatric update....................5 An approach to HIV treatment failure.....19 Is depression really a disease? ................30 PCT informing antimicrobial Stewardship? ..................................................32

COMPANY PROFILE

Acino committed to expansion and location .......................................................10

PRACTICE MANAGEMENT

Limiting fraud in the healthcare practice ...............................................................12

OPHTHALMOLOGY

Dry eyes cause tears .................................... 14

RESPIRATORY

Quality of life in COPD....................................15

DIABETES

Type 1 diabetes: The burden of mealtime insulin dosing ....................................................16 IDegLira vs basal-bolus insulin in T2DM...............................................................24

ONLINE CPD

Getting rid of actinic keratosis ..................18

INFECTIOUS DISEASES

Healthcare providers are key to reducing cervical cancer.............................20

CARDIAC

Strategies to manage VTE...........................21 Objective risk assessments in PAH optimise treatmen .........................................26

ASTHMA

Addition of LAMAs in asthma....................22

BLEEDING DISORDERS

How to distinguish AHA ...............................28

GASTROENTEROLOGY

Gut microbiome’s role in diseases............31

DIGITAL THERAPEUTICS

App helps manage children's mental health.................................................................. 33

ONCOLOGY

The Evolution of genetics in breast cancer...................................................34

WEBINAR REPORT

HIV 2022: An update.....................................35 Exploring schizophrenia..............................36 A discussion on connective tissue disease..................................................37

OPINION

How does motivational interviewing improve patient adherence........................38

PLACEBO

Beat the odds in severe brain injury .......39