MEDICAL ASSOCIATION OF SOUTH AFRICA

WHITE PAPER FOR THE TRANSFORMATION OF THE HEALTH SYSTEM IN SOUTH AFRICA

1. INTRODUCTION
The Medical Association of South Africa (MASA) commends the Department of Health for a comprehensive document that addresses the realities facing the South African health care system. MASA recognises and supports the urgent need for change in the existing health care system to achieve universal access to health care services for all South Africans. MASA acknowledges the efforts by the Department of Health to consult with stakeholders and understands the complexities surrounding health care reform. The Department has already made substantial progress towards a better health care system for South Africa. The challenge for the Department will be to implement mechanisms to achieve its objectives.

Related Legislation
It is recognised that many of the principles contained in the White Paper have already been incorporated in national legislation passed by parliament in the course of 1997. These include amendments to the Medical, Dental and Supplementary Health Services Professions Act and the Medicines and Related Substance Control Act. Issues impacting on doctors, in particular, are community service and dispensing. Comprehensive comment will therefore not be submitted in this report in respect of these areas. It is also anticipated that many of the enunciated principles, such as access to health information, will be included in the National Health Bill. Detail comment on these aspects will be incorporated in feedback on me National Health Bill after its release.

Practitioners of Alternative Care
In respect of Ethical Rule 9(11), it should be noted that the Interim National Medical and Dental Council of SA has resolved that this rule should be deleted, and that MASA has already drafted guidelines governing the relationship between medical practitioner's and providers of alternative care. A copy of those guidelines is enclosed as Annexure A.

With regard to non-discrimination in AIDS testing, the position outlined in the White Paper is supported by MASA. However, MASA believes that the right to confidentiality is not absolute. Doctors should be allowed to divulge information to a third party who is at risk even without the consent of the patient. This should be done only after the patient has boon counselled in this regard. A copy of MASA's ethical guidelines on HIV/AIDS is enclosed as Annexure B.

Donor, Agencies, NGOs and International Health
It appears from the White Paper that proposals on the role of donor agencies and non-governmental organisations as well as international health have been included. These proposals are supported in principle.

General
The White Paper contains essentially the same principles as the previous policy document of the Department of Health entitled "Towards a National Health System for South Africa" (1995). MASA has submitted extensive written comment to this document. This is to a large extent still applicable. Certain areas will again be highlighted in this representation. However, should the Committee however require more detailed comment, a copy of the previous submission could be provided.

Input has been gleaned from various MASA special interest and specialty groups, and specific responses have been included in the Appendix. This submission will be supplemented by oral representations to the Parliamentary Portfolio Committee on Health.

2. AREAS REQUIRING FURTHER CONSIDERATION
Notwithstanding the fact that MASA supports the broad objectives end proposals outlined by the Department of Health in the report. It is recommended that the following issues be considered prior to implementation of the proposed reforms.

2.1 DEFINING CORE SERVICES
MASA believes that all South Africans should have access to all health care services, regardless of their ability to pay. However, it is recognised that resource constraints may pose limitations and that choices will have to be made. It is therefore necessary that government should take responsibility for the clear definition of a comprehensive range of core services comprising primary, secondary and tertiary care.

A national advisory committee of expert should be appointed to define core services. Economic quality and ethical considerations should form an integral part of this process.
Failure to implement such initiatives will restrict access to necessary care, create unrealistic expectations, increase community dissatisfaction and ultimately have an adverse impact on the doctor-patient relationship.

It is recognised that the Department of Health has commenced the consultation process for the development of a core package of primary health care services. Initial comment has been submitted to the Department, a copy of which is enclosed as Annexure C

2.2 INTEGRATING THE PRIVATE AND PUBLIC HEALTH SECTORS
The private health sector should be seen as a valuable resource which complements the public health sector. A flexible approach needs to be adopted in Interfacing those two sectors according to regional needs and resource availability.

Government's concerns with regard to the private sector are recognised. However, caution should be exorcised in imposing regulatory constraints on the private health sector. These may inhibit the effective restructuring of the medical schemes industry, and may prevent the private sector from broadening access to cost-effective care of high quality to a larger portion of society.

Regulating fee structures in the private sector has historically shown to be counter-productive, and a major factor in the uncontrollable escalation of health core costs.

It is strongly recommended that there be widespread consultation with all stakeholders in the private sector prior to any regulatory intervention.

Further, it is recognised that the Department of Health has initiated the consultation process with stakeholders regarding the development of a policy for health care technology. MASA is committed to active participation in this process, and will provide input and submit comment where appropriate.

2.3 ALLOCATION OF RESOURCES AND THE FUNDING OF THE NATIONAL HEALTH SYSTEM
There is an urgent need to start implementing the health care reform proposals in South Africa. The financial analysis enumerated in the report demonstrates that additional funds will be required to implement the proposals. It is essential that government and other stakeholders support this process.

To manage expectation, provision should be made to educate the community regarding the scope and time-frames required to implement the proposed reforms. In addition, measures for mid-course correction should be planned to address unexpected budgetary deviations that may arise during the implementation process.

The success of the initiative to equitably distribute resources according to the budgetary reprioritization process will be determined by the timeous availability of accurate information. This process should be incremental, carefully managed and constantly monitored. Every effort should be made to upgrade the level of information prior to implementing reprioritization decisions. This need could be jointly addressed by the public and private sectors.

The introduction of a mandatory social health insurance for hospital services through the public sector will have financial implications and should form part of the national process of defining comprehensive core services.

MASA is actively involved in the consultation process regarding the implementation of social health insurance scheme for South Africa. The proposed policy is in line with MASA's philosophy, but concern has been expressed with regard to the administrative viability of such a scheme and the implementation of a dedicated tax outside of fiscal control. Comprehensive comment to this document will be submitted to the Department of Health in due course.

2.4 DEVELOPING HUMAN RESOURCES FOR HEALTH
The following Human Resource issues require further investigation:

2.4.1 Distribution of Human Resources
Conditions for doctors in the public health sector are rapidly deteriorating and have reached a crisis point. It is vital that the salaries; and working conditions of doctors in the public sector be addressed as a matter of urgency to prevent further deterioration and collapse of health care services in this sector. The emphasis should be on adequate communication systems, patient transportation and basic facilities. Moreover, urgent steps must be taken to ensure security for patients and health care professionals at al times.

MASA opposes the principle of introducing compulsory community service for the medical profession only. The medical profession should not be singled out. Policies introduced to address community service should be uniform and applicable to all other professionals. The position paper on community service of the Registrars' Association of Medical Faculties of SA, a special interest group of MASA, is enclosed as Annexure D.

The acute problems in underserved areas are acknowledged. A comprehensive human resource programme, linked so an incentive based system, should ideally be the mechanism to address problems in overserved and underserved areas. Further, there is a need to clearly do what constitutes rural areas and community services. Doctors should not be placed in an environment which has inadequate support.

While it is accepted that government to government contracts to staff underserved areas is a necessary temporary measure, it is vital that incentives be introduced to attract South African doctors to these areas. Further, it is imperative that assessment and monitoring mechanisms be established to ensure good patient care. These audit procedures should apply before, during and after the probatory period.

MASA is opposed to the introduction of restrictions placed on individual doctors who are appropriately qualified and registered with the Interim National Medical and Dental Council of SA to prevent them from entering private practice. Conditions in the public sector should be improved to make it attractive for doctors to work in this sector and doctors should retain the freedom of exercising their preferred option.

A document entitles "Strategies to attract Senior Medical Leadership to underserved areas in SA" of the Senior Hospital Doctors' Association of SA, a special interest group of MASA is enclosed as Annexure E.

2.4.2 Development and training of Human Resources
MASA has been actively engaged in issues relating to medical training and the role of general practitioners. Improvement of the curriculum and training for general practitioners appropriate to serve the needs of the people of South Africa is supported. Furthermore, general practitioners should be utilised to train doctors in the field of general practice whether in the primary, secondary or tertiary care setting, and students should be exposed during their training to general practitioners so that they can be seen as role models.

MASA generally supports the initiative by employers to improve remuneration policies and the salary grading system of public servants.

The aim to transform the public health service into a non-discriminatory organisation is supported. It is viral that the in process high standards be promoted at all times.

The multi-disciplinary approach towards providing comprehensive primary healthcare services in public sector facilities is appropriate, and should be encouraged. However, the recommendations to review legislation to broaden the scope of practice of health professionals (e.g. nurses, optometrists, etc.) requires careful consideration. In particular, the proposals to allow psychologists to prescribe medicine is of great concern. Psychologists are not medically trained and have no knowledge of pharmacology, physiology, anatomy, clinical medicine and the complex relationship between these subjects. They also have no physical examination skills which are acquired through six years of study in medicine. Such an initiative will have a serious and detrimental impact on patients. Pilot studies should be performed to investigate the cost-efficiency and appropriateness of various healthcare professionals as front-line providers. It is important to foster and environment that promotes a team approach to delivering healthcare services with the general practitioner being an integral part of the team.

3. ADDITIONAL MASA SUBMISSIONS [Annexures are not included]
Included as part of MASA's submission are the following documents prepared by MASA Groups:

Maternal, Child and Woman's Health - Chapter 8 (Annexures F and G)
- Submission by the South African Society of Obstetricians and Gynaecologists (SASOG)
- Submission by the SA Paediatric Association
Occupational Health - Chapter 14 (Annexure H)
- Submission by the South African Society of Occupational Medicine (SASOM)
National Health Laboratory Services - Chapter 16 (Annexure I)
- Submission by the National Pathology Group
General
- Submission by the Geriatric Society of South Africa (Annexure J)

4. CONCLUSION
The reform proposals outlined in the document prepared by the Department of Health pave the way for the introduction of an equitable health care system that reflects the unique needs of the people of South Africa.

Special areas have been highlighted in this report that should be considered prior to proceedings with implementation. It in essential that further debate on these matters takes place to identify workable alternatives, and to ensure successful and sustainable implementation of the healthcare reforms MASA is committed to this process and looks forward to continued consultation.