When the private health sector falls short

PROPONENTS on both sides of the NHI debate have emphasised improving service at public health facilities, Amrk Sonderup, Wendy Spearman and Nathan Geffen write

Published in Business Day: 2011/10/03 07:41:07 AM

PROPONENTS on both sides of the National Health Insurance (NHI) debate have emphasised improving service at public health facilities. They are right. Many clinics and hospitals are understaffed and poorly managed, with shortages of essential medicines and equipment. Patients have to wait in long queues. They are lucky if they see a pharmacist for assistance on the correct use of medicines. The reasons for this are many and complex. The fragmented apartheid health system, the poor leadership until 2008 on the HIV/AIDS crisis, under-resourcing and poor management skills have affected the public health system. The skewed distribution of resources between private and public healthcare is a crucial factor.

Medical schemes are the predominant way most private patients finance their healthcare. According to the Council for Medical Schemes, in 2009 there were about 8-million medical scheme beneficiaries — about 17% of the population. However, schemes don’t cover all expenses and many private-sector users have to pay for medical services.

By contrast, 70% of people predominantly use the public health system. According to the Health Systems Trust, per capita health expenditure in the private sector was nearly five-and-a-half times per capita public sector expenditure in 2009. Despite this, schemes do not cover the treatment of many diseases, with many patients falling into the void between the public and private sectors.

Perhaps spurred by the NHI discussions, private health providers are beginning to acknowledge that they need to do more and absorb a greater share of SA’s disease burden.

About two weeks before the release of the NHI green paper, the World Health Organisation marked World Hepatitis day. It passed fairly unnoticed in SA, a country where hepatitis B virus infection is endemic. Chronic hepatitis B infection accounts for about half of all cases of liver cancer in SA. Hepatitis C has a far lower prevalence but can cause chronic liver disease with high morbidity and mortality. Both infections are complicated in people with HIV. It is then ironic that treatments for chronic viral hepatitis are available in the public sector, but access in the private sector is more difficult where chronic viral hepatitis is not a prescribed minimum benefit (PMB).

Treatment of hepatitis C is with pegylated interferon, a medication injected weekly, together with ribavirin, a tablet taken daily. Treatment is expensive, requires specialist care and lasts for 24 or 48 weeks. Nevertheless, a public-sector patient with hepatitis C can access treatment. This is not the case for patients on medical schemes because hepatitis C is not a PMB.

Several schemes do cover the cost of treatment as an ex gratia benefit and patients thus benefit. However, the country's biggest health insurer, Discovery Health, does not. Discovery offers treatment only for hepatitis C on its top two most expensive options and then a substantial co-payment is levied. Even for the well-off, this creates an invidious choice: risk financial ruin or risk morbidity and even death.

Treatment for hepatitis B is also not covered by medical schemes. The exception to this is HIV-positive patients with hepatitis B, as they can readily access antiretroviral therapy, in which two of the drugs used are active against the hepatitis B virus as well.

We therefore have a clear situation in which public-sector patients with hepatitis are better off than private medical scheme ones. This paints a distinctly more complicated picture of the differences in public and private healthcare in SA to the one we usually read about. In this case, the public sector is absorbing a great burden and providing good service, while medical schemes leave patients without care. Not only is private medical care much more expensive but, in this case, it offers less.

Medical schemes such as Discovery must do their share and cover the full cost of chronic viral hepatitis treatment. The Council for Medical Schemes must take steps to ensure that treatment for chronic viral hepatitis becomes a PMB.

These are all opportunities for the private sector to show whether it is interested in doing more to relieve the burden on the public health system or whether it is just making rhetorical noise in response to the perceived threat of NHI.

Sonderup and Spearman are hepatologists at UCT and Groote Schuur Hospital. Geffen is with the Treatment Action Campaign.