Photo by Miguel Á. Padriñán: https://www.pexels.com/photo/syringe-and-pills-on-blue-background-3936368/
The South African Pharmacy Council (SAPC) has been given judicial go-ahead to introduce its Pharmacy-Initiated Management of Antiretroviral Treatment (PIMART) initiative, which will allow specially trained pharmacists to manage and prescribe medicine to patients with HIV and tuberculosis.
Pretoria High Court Judge Elmarie van der Schyff has dismissed an application brought by a doctors’ organisation – the IPA Foundation – for the setting aside of the programme.
She said the pilot project had emphasised the value of the initiative, which was in line with the World Health Organisation’s vision to promote widely accessible primary health care.
“The untapped value of pharmacists in fighting HIV was also emphasised by the efficient role pharmacies played in meeting health care needs and providing health care services during the Covid-19 pandemic,” she said.
“The need to widen access to first line ART and TPT therapy on a community level is not a figment of SAPC’s imagination but a dire need that is also evinced in other countries.”
The IPA Foundation approached the court, under the Promotion of Administrative Justice Act (PAJA), seeking to review and set aside the SAPC’s decision to implement PIMART.
IPA claimed that the SAPC had failed to give interested parties an adequate opportunity to comment before the initiative was implemented. It further contended that PIMART unjustifiably encroached on the domain of medical practitioners and was in conflict with legislation.
IPA also accused SAPC of misleading the Director-General of Health, claiming there had been extensive consultation with stakeholders, which led to the approval and issuing of permits for the initiative.
The SAPC said the application should be dismissed. It said pharmacy-provided primary healthcare was a well known and functional concept in South Africa and PIMART was simply a “widening of this”.
Referring to the background and context, Judge van der Schyff said, in line with WHO recommendations that all people living with HIV must be provided with ART, the department of health had requested the SAPC to consider and implement interventions that would ensure that patients had increased access to medicines.
This led to the SAPC requesting the Director-General in August 2018 to consider issuing permits to pharmacists who had completed supplementary training, to manage patients and to dispense medication under PIMART.
In March 2021, the SAPC published a notice for public comment regarding the adoption of PIMART. The first permits were issued in August that year.
However, IPA submitted objections outside of the timeline for comments. It said this was because its members were struggling with another wave of the Covid-19 pandemic.
“Pharmacists and doctors operate in distinct and separate professional domains, the boundaries of which are closely guarded and some tension exists … IPA’s objection to PIMART seems to be rooted, partially at least, in this professional tension.
“This is evidenced by its fear that the decision to implement PIMART might ‘open the floodgates’ and ‘pave the way for pharmacists to ultimately treat and prescribe other schedule 4 drugs in respect of acute illnesses’,” the Judge said.
She noted, however, that the National Drugs Policy, in line with WHO guidelines, promoted “task shifting” to advance access to medicine and that at primary level, prescribing should be competency based, not occupation based.
Any alleged adverse effect that PIMART held for a medical practitioner had to be considered against the need to expand primary health care services aimed at preventing and treating HIV and providing first-line ART therapy.
Judge van der Schyff said the initiative gave members of the public a choice as to whether they wanted to approach a pharmacist, who had been issued with a permit, or a general practitioner.
In considering procedural fairness, the judge said there was nothing sinister in the timing of the notice calling for comment, that the project was not something hidden in secrecy and “I find it improbable, as alleged, that none of IPA’s members had timeous knowledge of the board notice”.
The decision to implement PIMART also fell within the ambit of the SAPC’s powers.
Evidence also showed that the PIMART training course was developed to ensure that pharmacists who successfully completed the training would be suitably qualified to safely and effectively assist in providing ART.
Judge van der Schyff dismissed the review application and ordered IPA to pay the costs.
Professor Francois Venter, former President of the Southern African HIV Clinicians Society and Director of Ezintsha, an HIV research organisation at Wits University, commented, “I hope this is the end of it. The pharmacies are an essential part of the health system, and pharmacists internationally play a big role in expanding HIV services.”
Doing ‘the right thing’ for one’s health, be it eating well, exercising, or going for an annual HIV test or blood pressure check, is easier said than done. One way to nudge people to make these ‘right’ decisions is to offer rewards or incentives. Discovery Health Medical Scheme’s Vitality programme is probably the best local example of such an incentive programme.
While incentive programmes have made a splash in private healthcare, they’ve hardly caused a ripple in South Africa’s public sector. In fact, the only public sector incentive of any notable scale of which we are aware was the vouchers that were offered to people who got vaccinated against SARS-CoV-2. There have been several scientific studies of cash transfers and other incentives, but the data is relatively limited and the differences between studies were substantial, as indicated in this review of cash transfers for HIV prevention, among others.
Evidence from other countries has shown that a targeted public sector incentive programme could yield significant positive results. The Indian Government launched a programme called Janani Suraksha Yojana (JSY) in 2005, “with the goal of reducing the numbers of maternal and neonatal deaths” using a conditional cash transfer scheme to encourage giving birth in a health facility. In those who benefited from the scheme, there was a reduction of 4.1 perinatal deaths per 1000 pregnancies and a reduction of 2.4 neonatal deaths per 1000 live births.
As Spotlight has recently reported, South Africa is doing relatively poorly against its diabetes and hypertension targets and substantially better against its HIV targets. Yet, we can find no evidence that the Department of Health has given serious thought to incentive programmes in these various areas.
Some might argue that the impact of such programmes is unproven and that they are too expensive. No doubt, a carbon copy public sector version of Vitality is wishful thinking. But are there any elements of it worth copying or adapting for the public sector?
“It has always amazed me that incentives are always so OK for rich people like me, on Discovery, but somehow unacceptable for poor people ‘who should do it for their own good’ in the public system,” says Professor Francois Venter, who heads up Ezintsha at the University of the Witwatersrand. He describes it as patronising.
Venter says that while hugely complex issues like controlling non-communicable diseases (NCDs) and obesity can’t be solved with incentives, they could certainly be added to the very limited toolbox of the existing arsenal being used to prevent disease or death through early detection, testing, and screening. He says incentives “definitely should not be dismissed right off the bat when it comes to the 84% of people who rely on the public system”.
The power of ‘points’
An estimated 60% of diseases across the board are caused by unhealthy lifestyles, according to a 2022 study published in the International Journal of Environmental Research and Public Health. In line with such evidence, Discovery’s Vitality programme is primarily focused on encouraging its members to make healthier lifestyle choices.
“Vitality aims to leverage behaviour change techniques, most notably using incentives, to motivate or nudge members to adopt healthy behaviours,” says Dr Mosima Mabunda, who is the Head of Wellness at Vitality. She says that four core factors are implicated in most NCDs, namely an unhealthy diet, a lack of physical activity, smoking, and alcohol misuse.
The Vitality programme is complex and uses a wide range of incentives and rewards to motivate members, including giving members monetary rebates for healthy food purchases, subsidised gym membership, and a comprehensive points-based system that rewards a range of healthy lifestyle choices. These points can be converted to cash or used at a range of local retailers. There is an incredible variety of Vitality rewards that range from discounts on flights to discounts at movie theatres.
According to a Discovery report, the “overall impact of Vitality on mortality rates is significant”. By “making people healthier” they say they have achieved an average reduction in mortality of 13%.
Several experts interviewed by Spotlight point out that most of this data has not been published in reputable, peer-reviewed journals. Even so, it is certainly plausible that Vitality’s annual incentivised health check helps with earlier diagnosis of hypertension, diabetes, and even HIV. Similarly plausible is the idea that points may successfully incentivise some people to exercise more. Scepticism of the health benefits of other elements of the Vitality programme may well be warranted – it is hard to know without independent analysis.
Importance of early detection
The underlying logic of such incentive systems is typically that the savings due to behaviour change or early detection outweighs the cost of the incentives. Put another way, the private sector isn’t just doing this to help people stay healthy, they are also doing it to save money. The costs and benefits for state-run incentive programmes will obviously look very different, but there may well be cases where the benefits of incentives outweigh their costs.
It is also possible that in some instances incentives are actually needed more urgently by users of the public sector than the private. As Professor Harsha Thirumurthy, who is an expert on behavioural economics and health incentives based at the University of Pennsylvania points out, “the majority of Vitality members don’t face barriers like transport costs” or even being located many kilometres away from the nearest state facility.
Late diagnosis or poor disease control has high human and economic costs in both the public sector and private. According to a 2013 study published in the Global Health Action journal, uncontrolled diabetes caused 8000 new cases of blindness and 2000 new amputations in South Africa in 2009 alone. More recent statistics reveal the situation is getting worse. In 2018, then KwaZulu-Natal MEC for Health Dr Sibongiseni Dhlomo revealed that six amputations occur every single day – which equates to over 2100 a year – in that province.
And the financial implications are staggering. For example, a 2022 literature review that looked at the costs of treating common NCDs in South Africa, estimated the cost of treating one person for one year with medication for type 2 diabetes to be roughly between R1000 and R3500 in the public sector. In comparison, the study also looked at the costs of treating common complications of uncontrolled diabetes. For example, diabetes-related renal disease was estimated to cost roughly R67 000 per person per year.
Screening for diabetic retinopathy, an eye condition that causes vision loss, costs between R110 and R370 per person. In comparison, the cost of treating ophthalmic disease in people with diabetes is estimated to be R59 000 per person per year.
These are only the health system costs and don’t include the costs of serious complications and lifelong disability to individuals, families, and communities.
Barriers to healthy lifestyle choices
Most experts we spoke to agree that the Vitality programme in its entirety is too complex and expensive to be replicated at scale in the public sector. Additionally, helping the majority of the population make healthy lifestyle choices, particularly those around healthy diets and physical activity, is a mammoth task and exceeds the ambit and powers of the National Department of Health.
“It’s really important to appreciate that there are so many environmental, social, [and] structural factors that make it difficult for people to quote-unquote ‘do the right thing’ when it comes to health-related behaviours,” says Thirumurthy. “For example, people are constantly subjected to advertising of unhealthy food products. Many are living in environments that make it hard to eat a healthy diet even if they wanted to.
“To really make a difference, we have to take a step back and identify the overall system-level or structural changes that could be made to influence people’s diets and other health behaviours. We need to think about what types of government regulation and policy levers can be utilised to achieve better health outcomes,” says Thirumurthy, who is also the co-founder of South Africa’s first ‘nudge unit’, based at Wits University called Indlela: Behavioural Insights for Better Health, which is focused on identifying low-cost behavioural solutions to public health challenges.
As Spotlight previously reported, many of these issues are flagged in South Africa’s recently published Strategy for the Prevention and Management of Obesity in South Africa 2023 – 2028. But while most experts we interviewed felt the strategy flagged the right issues, there was also agreement that the strategy didn’t set out a realistic plan for dealing with those issues. And not finding ways to deal with these issues is costing a lot of money.
In 2018, the public sector cost of treating patients diagnosed with diabetes alone totalled R2.7 bn “and would be R21.8 bn if both diagnosed and undiagnosed patients are considered”, according to a 2020 report about the health promotion of NCDs published by the South African Medical Research Council (SAMRC). Moreover, in real terms, it is estimated that by 2030 the cost of all type 2 diabetes cases will soar to R35.1 bn.
According to Thirumurthy, incentive-based interventions represent one creative solution with the potential to help improve health outcomes and reduce the financial burden on the health system in the long term. “I’m not saying incentives or rewards-based programmes are going to save the day, so to speak. However, they do represent a small but important part of an overall policy package that is necessary to address NCDs. Global experience suggests this policy package should prioritise regulatory interventions, including taxes on sugary sweetened beverages and other unhealthy foods, but incentive-based interventions can certainly be a useful addition to a broader strategy or policy package,” he says.
A public sector annual health check?
Early detection is one area where the public sector could potentially benefit from copying a private sector incentive scheme.
Vitality’s annual health check is a free screening and testing consultation that includes HIV testing, mental health screening, body mass index evaluation, blood pressure check and a blood glucose test, among other things. Members are rewarded handsomely with points, simply for showing up. Critically, these checks are offered at many pharmacies and are thus relatively easy to access.
According to Belinda Kahler, Wellness Specialist for Vitality, there is data that suggests that the inclusion of a screening questionnaire for depression in their annual health check yields significant benefits for both the scheme and its members. She says that members who complete the screening and are flagged as high-risk are over three times more likely to seek professional help which “fosters early detection and management which reduces complications and ultimately reduces healthcare costs”.
One way a public sector version of this could work would be for the state to contract with nurses at private sector pharmacies and GPs to provide the checkups in addition to public sector clinics. This would make it much easier for people to access these checkups, and may well boost early diagnosis of diabetes, hypertension, and other diseases, especially if an incentive is included. For this to work, the public sector data systems to facilitate the capturing of measurements and test results will have to be in place, but presumably, work along these lines is already underway for the NHI data system that is being developed. Many public-sector clients already collect their medicines from private-sector pharmacies and some were vaccinated against SARS-CoV-2 at private-sector pharmacies – so it won’t be breaking entirely new ground to add checkups to the mix.
According to Thirumurthy, programmes that are ongoing, requiring daily or weekly action, are not feasible or sustainable for the public health system at this stage as they are too resource-intensive, requiring constant monitoring, and reward allocation. “But incentivising a once-off or annual behaviour, such as going for a vaccination or health check, is not only more likely to succeed compared to daily behaviours like going to the gym or taking a certain number of steps, it is also much more cost-effective and much easier for a government to implement,” he says.
He says addressing healthy lifestyles is incredibly difficult and preventive care interventions represent a more attainable goal for the National Department of Health. Screening, preventive care, and early detection save money and lives, but it is notoriously difficult to get patients to engage in the health system before they get really sick or experience noticeable symptoms. More often than not, patients seek care too late to prevent costly complications.
“Depending on the particular behaviour, test or screening combination that is incentivised, a programme like this could really move the needle on the intended health outcome and equate to money well spent in future averted healthcare costs,” says Thirumurthy.
Dr Brendan Maughan-Brown, who is the Chief Research Officer at the Southern Africa Labour and Development Research Unit, points out that “we really are going to have a collision of comorbidities in the next seven to eight years” fuelled by an ageing HIV population. “All these NCDs are going to become even more burdensome to the health system – already in some areas, over 25% of people over 50 are living with HIV. This is going to be a major challenge for the health system, insurers, and the NHI, so thinking about solutions now, including a proposed annual health check or screening, is a good place to start.”
What should incentives look like?
Once-off or annual programmes do not need to be expensive, according to Dr Sophie Pascoe, who is the Indlela Co-Director. “They would require a level of coordination, but there are many companies who I’m sure would be willing to come on board as sponsors. The big supermarket chains could subsidise grocery vouchers or incentives could be in the form of airtime backed by one of the big mobile networks, for example,” she says. These partnerships would “benefit everybody” by encouraging those targeted behaviours, while sponsors would profit from the exposure and an increase in their customer base.
“I think part of the problem is, when we mention the word ‘incentives’, everyone imagines a lot of money and big rewards. But the rewards don’t need to be big or costly,” she says.
Maughan-Brown, who is also an expert in behavioural economics and the behavioural determinants of HIV risk, says that for an incentivised preventive programme to be successful, there needs to be a comprehensive understanding of the various “hassle factors” faced by those who rely on the public health sector. What would be valuable to people? Transport, airtime, grocery vouchers, child care, paid leave from work or something else? He says a lot of work would need to be done to understand what rewards will work and there needs to be a level of flexibility because different people will need or value different incentives.
Pascoe, in turn, suggests that a lottery incentive could be added and would be inexpensive to augment an immediate but smaller reward that would be received directly after the health check or screening intervention, for example.
She adds that another difficulty when it comes to advocating for this kind of programme is that tangible benefits or outcomes will only be seen in the long term, while government is more receptive to programmes or policies with clear and quick results.
Venter has similar concerns. He says there is a perception that these programmes are expensive to implement and run. “But that is only part of the issue,” he says, “I find it bizarre that I get incentivised left, right, and centre by Discovery, yet every time we raise it for poor people, I get told ‘they should be doing it, anyway’. It makes no sense.” As it stands, Venter says that problematic and pervasive perceptions need to be addressed before any incentive-based programme will even likely be considered by policy-makers and government officials, and even international funders, civil society, and the media for that matter.
‘Already incentivised’
National Department of Health Spokesperson, Foster Mohale, told Spotlight that his department “is not against incentivisation but each preventive programme has its own issues and each community of health system user has different incentives for staying well”. He agrees that the “public health benefits of health checks and health screening” have the potential to “result in early detection and reduced costs to the health system”.
However, he says that these services are already incentivised and that considering interventions inspired by Vitality is “inappropriate”. Asked about the nature of the current public sector incentives, he said, “[It] depends on what one sees as an incentive! For me, a gym membership, Fitbit, express check-in queue or cheap flights are of no value and I regard them as an insult. For others, they rush to ‘benefit’. For the majority of South Africans, a visit from the [community health worker] is the incentive!”
Mohale argues that, by definition, incentive “means inducement, motivation, motive, reason, encouragement” and that, “in the true spirit of incentives”, “testing and screening services are incentivised through health promotion in ALL public health clinics, and in school health programmes”.
He says that “the massive programme for HIV testing [is] incentivised through free testing [and] specific clinics”. He adds that the department offers another incentivised programme in the form of adherence clubs, where groups of about 30 people who are on chronic medication meet regularly, share their experiences with each other and receive some screening and counselling from healthcare workers.
NOTE:Professor Francois Venter is quoted in this article. Venter is a member of Spotlight’s Editorial Advisory Panel. The panel provides the Spotlight editors with advice and feedback on the quality and relevance of Spotlight’s public interest health journalism. The Spotlight editors, however, remain editorially independent and solely responsible for all editorial decisions. Read more on the role and purpose of the panel here.
In the recent judgement handed down by the Pretoria High Court in favour of Board of Health Funders (BHF), the Council for Medical Schemes (CMS), Registrar of Medical Schemes and the Minister of Health were ordered to deliver a complete record, which will shed light on the moratorium on granting exemptions to medical schemes to provide LCBO benefits. The order directed the CMS and the Minister of Health to deliver all documents or information requested under Rule 30A within 10 days of the order, but all the respondents failed to meet the deadline.
After the ten-day deadline had passed and noting that the documents were still not produced and there was no appeal to the court order, the BHF was forced to return to court to seek answers. The BHF filed a contempt of court order on an urgent basis. In this application, the BHF highlighted that no complete record had been submitted even though the deadline for the Minister of Health and CMS to do so was on 24 July 2023. In response, the CMS and the Minister of Health opposed the contempt of court action and appealed the rule 30A judgement delivered on 10 July 2023. The Minister of Health, acting through his attorneys, allowed his own team to submit certain documents in terms of rule 30A, and the attorneys have stated that the delivery of the documents demonstrates good faith. This is despite the appealing of the judgement and order delivered in the rule 30A application.
The legal battle against the CMS and Minister of Health not only highlights their failure to comply with the court’s order, but also raises concerns about transparency and accountability within the healthcare system. This delay not only hampers the progress towards implementing affordable healthcare solutions, but also undermines public trust in the decision-making process of these regulatory bodies. This lack of adherence to court orders highlights the urgent need for effective enforcement mechanisms to ensure that court decisions are respected and implemented by the relevant parties.
In a media briefing on Tuesday, 8th August, the Council for Medical Schemes (CMS) sought to clarify its process and recommendations over the approved 5% increase to medical aid scheme contributions, levels above which the medical schemes must motivate for. As for low-cost benefit options (LCBO), the CMS indicated that they would only provide a report to the Health Minister by the end of the month. This could prevent medical schemes from applying for new LCBOs in 2023.
Mr Mondi Govuzela, Senior Manager of Benefits Management, explained that the 5% approved increase is based on the Consumer Price Index (CPI) for 2022, which indicated a 4.9% increase. Schemes therefore may raise contributions by 5%, in line with the Reserve Bank’s inflation prediction for 2024. A prudent percentage markup should be incorporated to take into account cost increases and demographic changes, he advised. Before COVID, contribution increases have typically been 2.4–5% above CPI. The years 2020 to 2022 saw contribution increases dip below CPI.
One of the cost drivers that Mr Govuzela noted in the media briefing was supplier pressure stemming from fewer doctors and specialists, who were pushing for higher remunerations. Increased costs elsewhere in the healthcare industry. On the member side, growing rates of chronic diseases, membership ageing and coverage for medical services also added pressure.
LCBO would appear to be a solution for many individuals to access private healthcare for at least some urgent conditions, but the CMS has yet to comply with a Pretoria High Court ruling ordering that they provide a report on their moratorium on granting exemptions to medical schemes to provide LCBO benefits. The case was brought by the Board of Health Funders (BHF).
As to what the CMS’s response to the LCBO ruling was, CMS Registrar Dr Sipho Kabane said that the CMS was preparing a report that would be delivered to the Health Minister “by the end of the month”, but would not be drawn on what it might say. The deadline for registering new benefit options is September 1.
In their circular explaining the decision increase, the CMS acknowledged the persistent macroeconomic headwinds facing medical schemes and their members, with a meagre 1% increase predicted for SA’s GDP next year. “Against the backdrop of the current adverse macroeconomic conditions characterised by multi-year higher interest rates due to stubbornly higher inflation rate, volatile domestic currency and surging energy prices and overall lacklustre economic growth, it is evident that most household budgets will remain constrained for a foreseeable future, leaving most consumers under a precarious financial position. To cushion members of medical schemes against further financial distress and the probable risk of losing their health insurance cover due to affordability constraints, medical schemes are advised to limit their cost increase assumptions for contribution increases for the 2024 benefit year to 5.0%, in line with CPI.”
One of the most damaging aspects of our public discourse on National Health Insurance (NHI) is the mistaken notion in some quarters that the only two options are NHI and the status quo. PHOTO: Rosetta Msimango/Spotlight
By Marcus Low for Spotlight
One of the most damaging aspects of our public discourse on National Health Insurance (NHI) is the mistaken notion that the only two options are NHI and the status quo. Often implicitly, sometimes explicitly, defenders of NHI suggest that any argument against NHI is one for maintaining the current system. Since the current system doesn’t work very well for most people, this line of argument gets some purchase, even though it is based on a false premise.
In his book “Which country has the world’s best health care?”, oncologist and bioethicist Ezekiel Emanuel outlines the key features of healthcare systems in 11 different countries. Two things that stand out are that health systems differ substantially between countries and that most systems are the relatively messy products of complex histories and political and other compromises. This latter point about the path-dependency of healthcare systems is an important point we will return to.
Many varieties
South Africa’s proposed NHI system is sometimes clumped together with systems in other countries such as Canada, the United Kingdom, and Thailand. At times this is fair, at times it skims over important differences.
For example, NHI will be a single-payer system, which is to say, the NHI fund will be responsible for almost all purchasing of healthcare services in the country. In some respects, Canada has a similar system, except that rather than one system for the whole country, they in effect have 13 single-payer systems for each of their provinces and territories. Even Thailand, at times referred to as an example of NHI, technically has three funds rather than one, although it resembles South Africa’s NHI plans in several other respects. In principle, a large single-payer should be able to negotiate better deals than several smaller payers, but on the other hand, having Canada-style provincial funds would be more closely aligned with South Africa’s current governance arrangements and in some provinces, like the Western Cape, chances are people would have more trust in a fund run by the province than in one run nationally.
Another thing that quickly becomes apparent when looking at the variety of healthcare systems out there, is that a simplistic dichotomy between NHI and private healthcare is a false one. Countries like the Netherlands and Germany have achieved excellent health outcomes with systems that are neither NHI-style systems nor examples of the private sector running riot. Though the details are significantly more complicated than this, you can think of the Netherlands and Germany roughly as having many strictly regulated medical schemes (called sickness funds in Germany) with scheme/fund membership being compulsory (with some exceptions). The German system is progressive in that people with higher incomes contribute more than people with lower incomes – an important difference from South Africa’s medical schemes.
Funds in the Netherlands are also not primarily funded directly, as with our medical schemes, but receive funding from a central fund via a risk adjustment process. Both the German and Dutch systems have significant social solidarity built-in in the way it institutionalises the cross-subsidising of the poor by the wealthy.
In South Africa, such a system could, for example, be implemented by dramatically tightening up the regulation of medical schemes, putting in place a progressive mechanism for cross-subsidisation between schemes, making scheme membership compulsory for those who can afford it, and, over time, using tax revenue to pay for scheme membership for the unemployed (although this last element, like NHI, does come with a big question mark on affordability. Those with long enough memories might remember that a system roughly along such lines was on the cards in South Africa around the turn of the century. (see for example the Taylor report of 2002 and this interesting paper.)
Getting to there from here
One striking thing about NHI in South Africa is that for all the column inches, submissions to Parliament, and oral hearings across the country and in Parliament, hardly anyone seems to have shifted their positions in the last decade and there has been very little serious consideration of alternative paths to universal healthcare.
Photo by Hush Naidoo on Unsplash
One reason for this is the sense that the design choices behind the NHI Bill were essentially decided on by a relatively small group of people in the National Health Department and the African National Congress (ANC) around 10 or 15 or so years ago. What followed since then often felt like an attempt at co-opting rather than meaningful engagement. This was particularly apparent in the way some members of the Portfolio Committee on Health continuously pushed people on whether they are for or against NHI, rather than engaging with the substance of people’s submissions. Though the boxes for public engagement were ticked, the reality was often a parody of what such engagement is meant to be.
We could have gone a different route. It would have been entirely feasible to have a process for NHI akin to the much more meaningful set of engagements we had for the Competition Commission’s Health Market Inquiry into the private healthcare sector. In that case, people could make submissions, be heard by the panel, and crucially, one never got the sense that the outcome was preordained. Such a process may in some respects have given government officials and members of Parliament a few more headaches, but it would also have built trust and understanding of the technical issues, and for major reforms like NHI trust and public understanding is half the battle.
The Supreme Court of Appeal has dismissed an application for leave to appeal by Solidarity and Afriforum over a 2021 court case where they challenged a condition by South African Health Products Regulatory Authority (SAHPRA) that the Johnson & Johnson vaccine be restricted to the government. SAHPRA said that this was not a condition that they had imposed.
On 26 July 2023, the Supreme Court of Appeal (SCA) dismissed an application for leave to appeal filed by Solidarity and Afriforum (the Applicants) on the grounds that there is no reasonable prospect of success.
The Pretoria High Court struck Solidarity and AfriForum’s application from the court roll on the grounds of an alleged lack of urgency, and the court also ordered them to pay SAHPRA’s legal costs which was filed in June 2021 by the Applicants, wherein they alleged that when SAHPRA approved and registered the J&J vaccine, SAHPRA imposed a condition that the sale of the J&J vaccine is restricted to the National Government. The applicants argued that SAHPRA was not mandated to stipulate the condition that only the government may purchase the J&J vaccine and questioned the legality of such a condition.
SAHPRA refuted this claim because this is not a condition that SAHPRA had imposed. Subsequently, the applicants proceeded to lodge an application for leave to appeal with the SCA . SAHPRA CEO, Dr Boitumelo Semete-Makokotlela said, “This court ruling indicates that SAHPRA is judicious in adhering to its mandate responsibly. We welcome the outcome of this judgement.”
The draft regulations were gazetted in January and consumers had until 21 July to comment. These regulations, among other things, propose the mandatory use of new and bolder warning labels on unhealthy food which include items high in salt, sugar, saturated fats and items containing artificial sweeteners.
Community Media Trust (CMT) is a not-for-profit company, mainly focused on health and human rights and has partnered with the Healthy Living Alliance (HEALA), a coalition of organisations focused on nutrition.
In February, CMT and HEALA staged a flash mob as part of the “Less Sugar, More Life” campaign in Cape Town ahead of the Finance Minister’s Budget Speech, advocating for an increase in the sugary drinks tax. They were disappointed by the announcement that the tax would be frozen for two years.
Following a massive media campaign on the draft regulations, CMT and HEALA successfully collected thousands of submissions.
CMT’s co-director Lucilla Blankenberg said the warning labels had been tested with audiences and researchers. If you’re a diabetic shopping for food and there was a clear warning label saying, ‘high in sugar’, the consumer won’t have to spend time trying to work it out because the message is simple.
The proposed warning labels are black and white triangles and would clearly indicate when food is high in sugar, salt and fat or contains artificial sweeteners.
“The reason the food industry is fighting back is because if food has a warning label, it cannot be marketed directly to children. Which means cartoons and animation that will attract children cannot be used to market a food item that has a warning label. If a pack has a warning label they can’t make any health claims whatsoever,” said Blankenberg.
“We won’t see the results immediately, but it will happen over time, especially for the children. With warning labels, it will be easier for parents to avoid buying certain food,” said Blankenberg.
HEALA’s communications manager Zukiswa Zimela said conversations proposing front of pack warning labels started in 2016.
Zimela said research for the campaign was initially done by the University of Western Cape to determine which foods qualify to have front of pack warning labels. She said the research gave more insight into what consumers thought of the current information on packaging as well as what the new warnings should look like.
“We started the campaign in May and went to eight provinces, mainly to educate and inform communities about the importance of front of pack warning labels and the food they were eating,” said Zimela. She said they found that many consumers agreed that they did not understand the nutritional information on food packaging.
She said the food industry had used scare tactics like saying warning labels would cause job losses which was “completely untrue”.
“This is not something new, warning labels have been done in other countries like Chile, Mexico, Peru and Columbia and there has been no evidence that jobs have been lost because of it. This is just undermining the government’s plan to get people to eat better.”
Zimela said HEALA will be monitoring the responses to the regulations. “Should the regulations be implemented, we need to make sure that they are not watered down or seen as useless.”
Sugar industry warns against “demonising sugar”
The South African Sugar Association (SASA) told GroundUp it had also submitted comments on the draft regulations, and that the front of pack warning labelling system was of particular concern to the industry.
SASA executive director, Trix Trikam, said: “The objective of this system is to encourage the reduction of energy/calorie intake, saturated fat and salt to prevent obesity and non-communicable diseases.
“It is well known and there is evidence that sugar is not the sole contributor of kilojoules to the diet and should therefore not be singled out in a regrettable out-of-context manner,” he said.
He said the warning labels should not be done in a sensationalist or alarmist manner “which seeks to demonise sugar” because that would have “a significant adverse impact on the sugar industry”.
Trikman suggested that the warning labels should instead reflect the calories in a food product. “SASA is also not convinced that the perceived cut-off values for sugar is evidence-based. A possible solution to that would be to use the perceived cut-off values based on percentage of energy value and not the amount of sugar per volume of product,” said Trikam.
“The draft regulations make it mandatory for a warning symbol to be placed on the front of pack labels for foods that exceed a perceived cut-off value for sugar. In order to avoid the warning symbol for sugar, food manufacturers will seek to find ways of removing sugar from their products. This will lead to a decrease in the demand for sugar and will ultimately negatively impact the livelihoods of those dependent on the sugar industry in the deeply rural areas of KwaZulu-Natal and Mpumalanga.”
Trikam said SASA is concerned about the obesity rates in South Africa but added that the solutions should be evidence-based.
Disclosure: GroundUp was once a project of, and still has a close relationship with, Community Media Trust.
The recent judgement by the Pretoria High Court in favour of the Board of Health Funders (BHF) carries substantial implications for medical schemes in South Africa. This follows BHF’s court application, which sought to compel the Council for Medical Schemes (CMS) to give a complete record, providing light on the LCBO’s decision-making process thus far.
The Court ordered the Minister of Health and the CMS to provide all of the papers listed in Rule 30A within 10 days of receiving the applicant’s notice of motion. The completion of this crucial milestone hinges on the provision of several documents, which we eagerly await.
This significant victory brings us closer to the ultimate goal of granting Medical Schemes exemptions to offer Low-Cost Benefit Options (LCBOs), which aim to provide greater access to affordable medical scheme benefits for low-income earners. The BHF’s success aligns with the mission of improving healthcare accessibility and advancing progress towards universal healthcare coverage (UHC) in the country.
In the main application lodged on 8 August, the BHF requested the High Court to:
Lift the moratorium that prevents medical schemes from offering LCBOs when the Council for Medical Schemes (CMS) refuses to grant applications for exemptions to medical schemes, pending the finalisation of LCBO guidelines.
Declare the failure by the respondents to develop and implement LCBO guidelines as irrational, unreasonable, and unlawful, as per Section 6 of the Promotion of Administrative Justice Act and Section 1(c) of the Constitution.
The BHF represents the majority of the country’s medical schemes and healthcare funders, encompassing schemes and administrators serving nearly 4.5 million individuals.
According to Charlton Murove, the protracted process of crafting a framework for Low-Cost Benefit Options has taken over seven years and is yet to be finalised. Many policymakers have criticised medical schemes for their lack of affordability. The proposed solution aims to address these concerns and move closer to the principles of UHC, ensuring that the healthcare system grants everyone access to quality and affordable healthcare.
Murove stated, “This application seeks to drive a progressive agenda for the public and private healthcare sectors, fostering collaboration to alleviate the current challenges in our healthcare system. The Council for Medical Schemes and the Minister have pivotal roles in implementing policies that enhance access to healthcare. However, progress with LCBOs has been hindered by the CMS’s failure to take the necessary steps for reform, despite the publication of demarcation regulations in 2016.”
The BHF’s victory in the High Court represents a significant step forward in the pursuit of affordable and accessible medical scheme benefits. By addressing the current burdens faced by the state and ensuring that medical scheme premiums remain affordable, we can strive towards a healthcare system that benefits all South Africans.
According to a 27-page ‘factsheet’ purportedly produced by the Department of Health and the Presidency, the National Health Insurance (NHI) scheme would be funded through a payroll tax and additional personal income taxes. There are however better ways to go about this, according to a number of experts who weighed in on the topic.
Professor Alex van den Heever said that the payroll tax plan is misguided, according to Daily Investor. In the same vein as Unemployment Insurance Fund (UIF) payment, both employers and employees would make contributions to a payroll tax.
But Van den Heever criticised this, saying that those who suggested this do not have the qualifications to make financial comments such as NHI funding.
“They talk of introducing payroll taxes. You don’t introduce payroll taxes for a general government allocation,” he explained. “Payroll taxes are for contributory systems where you get a specific benefit or entitlement for what you contribute.”
The term “payroll taxes” in relation to funding NHI does not make sense, he said. Discussions on raising taxes and a new payroll tax shows that the government does not know how to fund the NHI.
He called them an “incredibly naïve set of fiscal proposals that you cannot even consider implementing,” and that they were “incoherent from a public finance perspective.” Introducing them as is would be politically suicidal: the tax base is already overburdened, and raising taxes beyond a certain point results in a reduction in taxes actually collected.
“It is very dangerous to overstress your tax bases. We are hitting the limit on the amount you can fund the government and the public health system from taxes.”
Huge tax increases needed to fund NHI
Van der Heever’s viewpoint is shared by Connie Mulder, Solidarity Research Institute head and Ryan Noach, Discovery Health CEO.
Mulder said trying to fund NHI through additional taxes is unfeasible because of the tremendous amount of money needed.
Mulder said that the massive additional taxation would “crush South Africa’s economic outlook.”
It is naive for the Department of Health to assume that medical aid contributions will be funnelled into a national health insurance scheme, said Noach. The NHI scheme would force South African taxpayers to pay much higher taxes but cut their healthcare entitlement by 72%, and would provoke a tax revolt.
South Africa has a unique situation where a very small tax base of 5.5 million people funds nearly all government expenditures, accounting for 80% of public healthcare funding, he said. Notably, their after-tax disposable income is used to pay medical aid and private healthcare.
The single-funder model described in the NHI Bill would not be able to achieve the government’s goal of equitable access to healthcare, Noach told Daily Investor. This is a model which Discovery Health does not endorse, calling it not only “risky and inefficient” but also not likely to be equitable because “cross-subsidies cannot be properly managed”.
He reiterated earlier comments where he said that the NHI Bill would have no immediate impact on medical schemes, but once it is fully implemented (with “implemented” remaining undefined), medical aid schemes would only be allowed to offer what is not covered under the NHI – at the discretion of the Health Minister. This would make NHI a single monopolistic funder for the NHI package of services, which he had said in an earlier interview with Newzroom Afrika was without a parallel anywhere in the world.
Even though implementation is a decade away, this is going to drive off health sector investment, Noach said.
Noach recommended a multi-fund framework, which he described as “not only less risky and faster to implement, but also ensures that cross-subsidies are managed to ensure that social solidarity is achieved”.
Collaboration between the private and public sectors is the only way financial integrity and sustainability is achievable, something which has been built on the successful COVID-19 partnerships.
NHI ‘charade’ – but Obamacare offers an alternative
Business Leadership South Africa CEO Busi Mavuso has a similar view – and didn’t mince her words. According to Mavuso, NHI as currently envisaged, was a “charade” without any thought to funding, according to Moneyweb. One that would leave all South Africans worse off, and recommends instead a private-public partnership.
She also pointed to the public–private partnership behind South Africa’s COVID-19 response. The two entities sourced resources, rolled out vaccines and funded other interventions.
“It was a clear demonstration that national health outcomes are achieved faster and more efficiently when government and business work together, drawing on their respective strengths,” she said.
“With the right incentives, the private sector can complement government efforts, speed up the investment needed and reduce costs to the state and users.”
One viable alternative to the NHI’s single buyer model was the US’ Affordable Care Act (aka Obamacare) in the US, wherein health insurers provide minimum cover, with the state subsidising those below a certain level. Insurers are however able to compete to offer coverage.
One other disadvantage of South Africa effectively ending the private sector was that it would discourage internationally mobile businesspeople from working in the country.
The Passing of the National Health Insurance Bill on 12 June 2023 by parliament has many stakeholders in the healthcare industry concerned as to what the implications are. The reality is that there is a long and challenging process ahead, and the NHI Bill has many years to go before all of its provisions could be implemented.
Putting all the challenges and debate aside, Jacqui Nel, business unit head of healthcare at Aon South Africa, highlights the salient points that are at the heart of the matter. “First and foremost, I would like to affirm that the private healthcare sector needs to focus all its efforts on objectively collaborating with all parties concerned to achieve a stronger and affordable healthcare solution for all South Africans. The concept and ideals of providing universal health coverage should not be in dispute.”
“The overarching principle of the NHI bill is to provide universal health coverage and social solidarity, providing all citizens with access to the same essential health care benefits, regardless of their financial means,” she adds.
However, the road to successfully implementing NHI is a long and costly one, with many experts saying it can take up to 15 years to achieve, if not more. Purely from a legislative point of view, there are no less than 11 pieces of legislation that will need to be amended to align with NHI objectives, and this is an onerous process.
This includes:
National Health Act
Mental Health Care Act
Occupational Diseases in Mines and Works Act
Health Professions Act
Traditional Health Practitioners Act
Allied Health Professions Act
Dental Technicians Act
Medical Schemes Act
Medicines and Related Substances Act
Nursing Act
And various Provincial Health Acts.
The first of many court cases are already making headlines. “On the constitutional front, one of the 11 pieces of legislation requiring amendment is the National Health Act, which governs the ‘Certificate-of-Need’ (CoN), a piece of legislation that would dictate to private sector doctors where they are permitted to practice and what services they may provide. This ‘CON’ is essential to government to control doctors under the NHI plans and is being challenged by trade union Solidarity and six other parties,” says Nel.
About the NHI Bill
The NHI Bill lays out the duties and functions of the NHI Fund, which are primarily to strategically purchase health care services based on the principles of social solidarity. All permanent residents and citizens will be eligible as beneficiaries of the “Fund” as it is referred to; and temporary residents and foreigners will have access to emergency medical treatment and access to other health services as determined through a mandatory travel insurance.
“The Bill states that eligible beneficiaries will be able to access health services through registering as a user of the “Fund”. Each member will have a number that is unique to them and their dependents. The Fund will then reimburse health care providers directly for services rendered, provided they have met the accreditation requirements. It is envisaged that comprehensive health services benefits must be made available and these services will be determined by the Benefits Advisory Committee,” explains Nel.
The Bill also refers to the establishment of the ‘Board of the Fund’, and the remuneration and reimbursement of the members of the Board which will be determined by the Minister of Health in consultation with the Minister of Finance. “There are various other functions of the fund for which further administrative departments will need to be set up to address planning, benefits design, price determination, accreditation, purchasing and contracting, payments, procurements, performance monitoring and a risk and fraud prevention unit,” says Nel.
However, there are major points of concern that remain and will need to be addressed to facilitate any implementation of the NHI into South African society, which include:
Ministerial powers, good governance and accountability.
Role of the different spheres of government.
Role of medical schemes.
Tax implications for taxpayers, both from an employee and employer perspective.
NHI funding models – increased taxes?
Health financing expertise.
Training of healthcare providers – consequence management.
Service delivery at state facilities and healthcare facilities.
Infringement on the right of choice.
Lack of detail around major parts of the NHI Bill.
In summary, this Bill is the roadmap to NHI, but many other pieces of legislation will have to be amended, and a crucial element is currently still missing which is the cost of NHI and what the basket of services will include. “To enable the NHI will require an appropriation bill from National Treasury to detail how the NHI is going to be funded. However, detail on this has been slim, while government’s finances are heavily constrained and look likely to worsen in the future with various global and local factors coming into play,” says Nel.
“We fully expect that there are going to be significant challenges to the many technical and restrictive provisions contained within the NHI Bill, and these challenges may well alter its entire substance, and there is also the prospect of political shifts that could have a material impact on health policy going forward. We simply do not see any material shifts to the private healthcare sector anytime soon,” Nel explains.
What is certain is that the Bill in its current shape and format is unlikely to remain as it is today. “While the NHI Bill raises serious concerns, there is no disputing the need for structural change. There will be much debate and negotiation in the years ahead in unpacking the strengths and weaknesses of current public and private healthcare systems, and we look forward to a rational and workable solution to the achievement of better healthcare and to assist in a workable solution for all South Africans,” Nel concludes.
