THE Health Department has asked doctors to stop threatening to strike and to work with them to implement the Occupation Specific Dispensation (OSD). The department said threats of strike action therefore go against the spirit and commitments made by the parties in implementing the OSD. The department urged any dissatisfied party to work with it in resolving any problems encountered in this process. It said the important work of delivering quality healthcare to those who desperately needed it should continue undisturbed. The SA Medical Association (Sama) has complained that salary payments under the OSD have been poorly managed. Some doctors have been underpaid, while others have been overcompensated beyond their salaries and had had to pay money back to the state. The department said it was "working closely with doctor unions" to solve problems. The department was encouraged by the fact that so far well over 96% of the process had been successfully implemented and the few remaining cases under dispute were receiving attention.

SAPA, 2 March 2010

NETCARE is to spend R800 million in the current financial year adding capacity to its existing hospitals to cater for increased demand, especially in KwaZulu-Natal. Chief executive Richard Friedland said the hospital group had applied for licences with the Department of Health but would not divulge the number of applications. According to its annual report for 2009, approval for an additional 233 beds had already been received. The company currently has 8 766 beds, which represents seven percent of total beds registered in South Africa, including state facilities. The Waterfall Hospital that is being built in Midrand will add to this total. Friedland said the first phase of the company's public-private partnership project in Lesotho was almost ready and the three clinics would be commissioned next month. Likotsi and Qoaling clinics would be inspected this week and Mabote would be assessed later this month. Construction of the hospital that forms part of Lesotho project will take two years and the completion date is set for March next year. The 452-bed hospital is expected to be operational from September next year. The entire project will cost R1.1 billion. Netcare will assess the public-private partnership projects announced by Finance Minister Pravin Gordhan two weeks ago when they are advertised to check if it would be appropriate for the company to submit a tender. In his review in the annual report, Friedland said Netcare fully supported the objectives of the proposed national health insurance (NHI) system. However, he said, the group recognised that the biggest stumbling block in implementing the NHI and other reforms were resource and funding shortages. He said the funding challenge exacerbated by the historical underspending in the public sector and the significant burden of disease in South Africa grew more pressing with the widening revenue deficit as recessionary pressures contracted the national fiscus.

Slindile Khanyile: Business Report,

A COURT challenge that could affect how much medical schemes pay healthcare providers may remain unresolved for months, with the threat of a large increase in the guideline tariffs hanging over schemes and members. The legality of the Department of Health's 2009 Reference Price List (RPL), which schemes use to set benefit rates, and doctors and other healthcare providers use to set their service rates, is being challenged. The South African Private Practitioners' Forum (SAPPF), 20 other medical professions' associations, the Hospital Association of South Africa (Hasa), and emergency services providers ER24 and Netcare 911 allege that the 2009 RPL process was illegal and procedurally unfair. Judge Piet Ebersohn reserved his judgment this week, but not before he granted an interim interdict that prevents the Health Department from producing any new tariff lists until the matter is resolved. Kerry Williams, the Webber Wentzel attorney for the SAPPF and the other associations, said this means the RPL, which should be published in September, may not be published until any appeals are finalised. No list was published for 2010. Last year, with the court action pending, Health Minister Aaron Motsoaledi announced "an interim and temporary" increase of 7.9 percent in the tariffs. Much of the arguments in the North Gauteng High Court related to whether the Department of Health followed the National Health Act regulations and was fair to providers during the RPL process. At issue is the Health Department's call for, and subsequent rejection of, healthcare providers' practice cost studies. The department rejected most providers' cost studies for failing to meet the required sample sizes, or having unacceptable costing or coding methodologies. Court papers reveal that the department was unable to verify any of the cost studies, because this was "too cumbersome and time-consuming". It then simply applied a 10.7-percent increase to the 2008 RPL and published it as the 2009 RPL. The SAPPF and the other associations say the department incorrectly rejected the cost studies, and should have at least considered other aspects of the submissions, such as the suggested new codes and various anomalies in the RPL. The practitioners argue that the guideline rates are now too low to cover many practices' costs. ER24 and Hasa are arguing that the RPL regulations are not valid and that the department's rejection of their alternative costing methodologies is unfair. The Health Department has defended its actions and is challenging the SAPPF and the other associations' right to bring the application.

Laura du Preez: Personal Finance,

THE Health Department is redesigning the new antiretroviral tender in the hope of procuring cheaper ARV medicine, amid claims that South Africa pays about 30 percent more than the global rate for the drugs.

The government will start procuring drugs under the new tender from June, and the Clinton Health Access Initiative (Chai) is helping the Health Department design a tender that will enable it to secure cheaper antiretroviral drugs for what is now the world's largest HIV treatment programme.

Last month, the DA's Mike Waters wrote to Health Minister Aaron Motsoaledi asking him to source the drugs overseas if they were cheaper than locally manufactured versions. But the department has long been working behind the scenes to find cheaper sources.

Waters said the previous tender requirement that companies be locally owned meant paying 30 percent more than necessary. "The government is helping the local pharmaceutical industry, but causing the deaths of people who cannot afford to pay for their treatment," he said.

Vishal Brijlal of Chai said there was an urgent need to minimise and control ARV costs and improve the efficiency of laboratory services in South Africa.

Around 40 percent of the HIV/AIDS budget is now spent on ARVs, according to the Treasury.

"It is partially correct to say that South Africa pays too much for ARVs," Brijlal told the Budget and Expenditure Monitoring Forum (BEMF) meeting.

For example, the price of the active ingredients for efavirenz, one of the most widely prescribed ARVs in South Africa, was high when the last tender closed in March, 2008. By May, 2008, it had dropped 45 percent, but South Africa did not benefit from the reduction, said Brijlal.

"We need to ask the question whether the drug company had a moral obligation to sell the drug at the lower price," said Brijlal.

The last tender catered only for price increases, not decreases. New tender conditions are expected to rectify this.

He said that when criticised, drug companies often said governments got access to the drugs at the lowest median international price. South Africa, as one of the world's biggest buyers, should get the lowest price, not the lowest median price, according to Brijlal.

He said Chai was not a drug buyer, but had agreements with 72 countries, and pooling their volumes gave it a powerful negotiating platform. South Africa is not part of this pool.

Chai makes each supplier sign an agreement to deliver a drug at a price no higher than the negotiated ceiling.

Brijlal said recent negotiations would see efavirenz drop by between 35 percent and 40 percent below the current tender price.

South Africa is changing its first-line regimen from April 1 to tenofovir, 3TC and efavirenz. At current tender prices, this would cost the government R4 000 a person a year. The Chai initiative would bring this down to R2 200.

The current regimen of d4T, 3TC and efavirenz costs R2 080 a person a year. Chai can procure this combination at R1 300 (excluding VAT and freight charges).

The new guidelines are poised to remove d4T (stavudine) as a first-line drug because of debilitating side effects including lipo-atrophy, peripheral neuropathy and lactic acidocis. But patients doing well on d4T might be kept on it.

Chai has also helped generic companies develop cheaper active pharmaceutical ingredients.

Brijlal said that if the tender process was transparent the new treatment guidelines could lead to savings.

Brijlal urged clinicians and activists at the BEMF meeting to pay close attention to business relationships between pharmaceutical manufacturers that might prevent some drugs reaching South Africa.

He said lopinavir/ritonavir, which was urgently needed for adult and paediatric HIV, remained expensive and was not available in the required formulations.

For children a heat-stable version needed to be registered urgently as the health system now relied on a solution that required refrigeration.

Another critical drug is the fixed-dose combination that combines tenofovir, 3TC and efavirenz in a single pill that is taken once daily.

This is also not yet available in South Africa, and activists have questioned whether the business relationship between Aspen and Matrix has prevented a much cheaper generic version of the drug being marketed in South Africa.

Commenting on the matter, Aspen CEO Stephen Saad said: "You cannot register the generic until the innovator has been registered - it is not registered."

Saad said their files were with the Medicines Control Council awaiting registration.

However, a council source said Saad's comments applied only to individual products. "If the three separate innovator drugs (or any combinations) are registered, which is the case in South Africa, the fixed-dose combination can be registered. This has happened before."

Dr Andrew Boulle of the University of Cape Town said the tender offered South Africa "an opportunity to get it right, given our enormous purchasing power".

"We should not allow this tender to go ahead unless we get it right. We need to ensure we get the one-pill-once-a -day regimen packaged in adherence-promoting 28-day blister packs with the days of the week indicated. Well-prepared treatment literacy material should be included in the pill packets," he said.

The Treatment Action Campaign said the coming tender must include special provisions that allow for companies to submit bids involving drugs such as the tenofovir-3TC-efavirenz fixed-dose combinations not yet registered here but already approved by stringent drug regulatory authorities such as the US Food and Drug Administration.

The TAC also called on the Health Department to commit itself to procuring available fixed-dose combinations and the council to fast-track the registration of all crucial ARVs and their combinations to ensure a competitive tender.

Anso Thom: Health-e News Service via The Cape Argus,

THE finer details regarding the operation and financing of the ANC Government's controversial planned National Health Insurance (NHI) scheme still have to be worked out and the ministerial advisory committee still has to do a lot of "homework" before a White Paper can be tabled.

However, what's becoming increasingly clearer is that the ANC is determined to start introducing NHI in SA - and as soon as possible.

Hardly had the New Year arrived when President Jacob Zuma emphasised during the ANC's 98th anniversary celebrations that Government was forging ahead with the implementation of NHI as part of a 10-point plan. At the same time, Zuma gave assurances that all stakeholders would be consulted before the necessary legislation is approved by Parliament. But there's a great deal of scepticism in the private sector about how much other opinions and opposition to the legislation will be taken into consideration.

Though plans to correct the inequalities between private and public healthcare - and making healthcare accessible to all South Africans - have been on the party's agenda for many years, they've been strongly prioritised since Zuma took office. And everything indicates Government will do its utmost to get the NHI wheels rolling as soon as possible, regardless of the criticism and scepticism of how feasible the plan is.

Though stakeholders generally agree the current distorted healthcare dispensation -where only about 7,5m South Africans have medical insurance and access to private care, while the majority have to rely on poor and overloaded State facilities - isn't sustainable and that the sector is in urgent need of revision to make it more accessible and affordable, the debate about the feasibility of such a system in a developing country like SA continues to rage.

If it's failed in richer societies - such as in Canada or Britain - how can it succeed in an African country with a large developing population? How will SA's health authorities succeed in bringing facilities in the public sector up to standard more quickly and manage them efficiently if they haven't been able to do so over the past 15 years? How will the exodus of medical practitioners - the core on which the ANC's delivery plans are based - be halted? Those are just a few of the disturbing questions raised.

The differences over the NHI plan were again shown clearly by round-table talks arranged by the Helen Suzman Foundation (NSF), in conjunction with the Open Society Foundation, in December 2009. To lead the discussion, Tebogo Phadu, of the ANC's policy unit and the party's health task team, put the ANC's case for an NHI, while independent health economist Alex van den Heever gave his views on the matter. In many respects, both also represented the views of other parties in the pro and anti NHI camps.

In a summary of the proceedings on the HSF's website, Phadu says the ANC's focus involves a reform path that's "interconnected" and doesn't simply aim at getting the public sector into shape but will result in the integration of the current two-tier health system.

This will result in the establishment of a public NHI fund that will be pooled to pay for services covering every South African citizen. It will involve a free service point with access to public and private healthcare providers, which will cut out wastage in the current system and will control costs by cost-efficient practices, capitation tariffs and wholesale buying, Phadu reported.

The insurance fund will apparently be supported by an SA Revenue Service type of organisation outside SA's national Budget system, will have a great deal of accountability and be managed by specialists and dedicated professionals. It won't be strictly bureaucratic and will be run at a cost of 3% to 4% of the total cost.

In that NHI dispensation there will still be room for medical schemes to be part of an integrated provision system. The system will put the whole healthcare system in a better position to influence the behaviour of suppliers, with the major share of the money in a single channel, said Phadu.

In an interview with industry journal Medical Chronicle, Phadu said the ANC task team's recommendations will be used as the basis for the negotiations of the ministerial advisory committee (appointed in November) with healthcare stakeholders before an official document for comments and public information is issued.

However, Van den Heever is openly sceptical about the feasibility of an NHI, saying inadequacies and problems - including the poor quality of the ANC document that's meant as a starting point for the advisory committee. Van den Heever says the entire debate about health reform has become very complex. It's therefore extremely important to obtain clarity about key conceptual elements, such as finances and institutional design.

He argued the standpoint on a two-tier system represents a distorted debate and diverts attention from what's really necessary in a health system: competent authorities that haven't existed since 1994. He gave many mechanisms, including legislation, as examples that can be used to integrate health systems but aren't or haven't been applied. He says numerous instruments are indeed present in the current system but their inefficient use contributed a great deal to the distorted growth of the private sector at the cost of public health services.

"Trying to implement a financial model to solve an institutional problem created a false debate and is a non-starter. The overall issue of health reform is the subject of the structure that controls health provision - a structure that's neutral and apolitical;' Van den Heever says.

The Medical Chronicle reported in its January issue further criticism comes from Professor Joe Veriava, head of internal medicine at the University of the Witwatersrand. A complicated plan and economic jargon won't solve the problem of an already overburdened system, he says. Public hospitals are already being run at 100% bed occupancy. In some of the wards of the Charlotte Maxeke Hospital there are 12% deaths. "We need more beds, we need more financing and we need workable systems to allow the public sector to use spare capacity in the private sector," he says.

Though the ANC is naturally very eager and in a hurry to carry out its election promise of affordable medical care for all, the financial and technical implications of its NHI plan could possibly become a spanner in the works. It will be interesting to see all the things the ANC does to keep the NHI gears turning

Wilma de Bruin: FinWeek,

THE cost implications of the proposed National Health Insurance (NHI) will only be known once details of the scheme have been finalised, according to the Health Ministry. In a statement following the second meeting of the ministerial advisory committee (MAC) on NHI, the Ministry insisted implementation of the NHI was "on course". The MAC was established by Health Minister Aaron Motsoaledi last year to advise him on how best to implement the scheme. It is made up of experts in various fields drawn from South Africa and internationally. The Ministry said the agenda of the second meeting focused on substantive issues relating to the workings of the committee and the technical content of the NHI, a report on the economic benefits of NHI, and the health information system to support the scheme. The proposed transitional arrangements from the current arrangement to NHI were presented and discussed. Discussions revolved around the timing of key policy and process steps, completeness of activities and feasibility. The meeting also developed plans aimed at ensuring that the public would remain informed at all times on the NHI, especially once the document had been released for public comment. The committee discussed in detail the various costing models for the NHI based on the inputs by a number organisations on the matter.

SAPA,
Health plan 'on course'

THE cost implications of the proposed National Health Insurance (NHI) will only be known once details of the scheme have been finalised, according to the Health Ministry. In a statement following the second meeting of the ministerial advisory committee (MAC) on NHI, the Ministry insisted implementation of the NHI was "on course". The MAC was established by Health Minister Aaron Motsoaledi last year to advise him on how best to implement the scheme. It is made up of experts in various fields drawn from South Africa and internationally. The Ministry said the agenda of the second meeting focused on substantive issues relating to the workings of the committee and the technical content of the NHI, a report on the economic benefits of NHI, and the health information system to support the scheme. The proposed transitional arrangements from the current arrangement to NHI were presented and discussed. Discussions revolved around the timing of key policy and process steps, completeness of activities and feasibility. The meeting also developed plans aimed at ensuring that the public would remain informed at all times on the NHI, especially once the document had been released for public comment. The committee discussed in detail the various costing models for the NHI based on the inputs by a number organisations on the matter.

SAPA, 25 February 2010

THE government, which expects to spend R7 billion on antiretrovirals (ARVs) next year, wants to push for the local production of key active pharmaceutical ingredients (APIs) as part of a broader plan to leverage local procurement and boost the pharmaceutical industry. This is according to the latest version of the industrial policy action plan (Ipap) released last week. Industry players have welcomed the development, but cautioned the government to ensure the plan is viable as investment will require hundreds of millions of rands. South Africa is the largest market for ARVs, with almost one million people receiving the AIDS treatment. Last year, the government spent R2.8bn on ARVs and that figure is forecast to escalate to R7bn next year. The Ipap document says that, apart from the economic burden, the figures show that there is a risk to the security of supply for these drugs. Two years ago imports were R16bn, while exports were R1.2bn. It said the export market had been under significant pressure due to the crisis in Zimbabwe, which accounted for 50 percent of South Africa's pharmaceutical exports until 2001. It also warned of "competition from exports from India". Stavros Nicolaou, the chairman of Pharmaceuticals Made in South Africa, said the project had to make sense from a capital investment and trade deficit point of view. He said the project also had to attract investors and avoid becoming a white elephant. He said the feasibility study that was currently under way would have to be digested, but with government support and the right technology, it would hold appeal. Vicki Ehrich, the chief operating officer of the Pharmaceutical Industry Association of SA, said the country was a very small market for pharmaceuticals, let alone active chemicals. The Department of Trade and Industry said the objective was to capture at least 50 percent of South Africa's demand for ARV APIs by 2013. The department said the idea was to incentivise investors internationally to exploit the high demand for ARVs that the country offered, set up plants and produce locally. Other opportunities identified by Ipap included local production of reagents of HIV/AIDS diagnostics under licence, production of vaccines under licence and removing constraints to clinical research.

Slindile Khanyile: Business Report,

US PRESIDENT Barack Obama has moved to revive his stalled healthcare overhaul with a new plan to make insurance more affordable and bolster federal authority to regulate premium hikes. Obama's proposal gives the Health and Human Services Department new authority to keep escalating healthcare costs under control. The overhaul plan, expected to cost $950bn over 10 years, is Obama's attempt to bridge the gap between stalled healthcare legislation passed by the House and Senate last year. The proposal would cover 31-million uninsured Americans. It also adds $10bn in industry fees to help close the so-called doughnut hole in drug coverage for elderly Medicare patients and bans deals in which pharmaceutical companies pay makers of generic medicines to keep cheaper copies of brand-name drugs off the market. The move is a reversal after months of the White House leaving details of the largest US medical overhaul in more than four decades up to congressional Democrats. Obama had invited Republican leaders and top congressional committee members to a meeting last week, calling on them to release a "comprehensive bill" of their own that would cover millions of uninsured Americans and reduce rising medical care costs. He urged legislators to attend in "good faith" as he decried "jaw-dropping" insurance rate increases he said underscore the need for remedies. Obama has this month singled out several companies for high premium increases, including a subsidiary of WellPoint, the biggest US insurer of individuals and small businesses. In his weekly radio address on Saturday, he said customers of Anthem Blue Cross of California recently "opened up their mailboxes to find a letter" containing news that it wanted to raise premiums "by an average of 25%, with about a quarter of folks likely to see their rates go up anywhere from 35% to 39%". His plan includes the creation of a government panel to set rules for reasonable rate increases. The proposal, first advanced in legislation introduced by Democrat Senator Dianne Feinstein, would create a seven-member health insurance rate authority to make recommendations on rate reviews and approvals. It would include consumer representatives, an insurance industry representative, a doctor, and experts in health economics, actuarial science and related fields. It would publish an annual report on insurance market behaviour, the official said. Under the proposal, the Health Secretary could also delegate enforcement to a state insurance regulator to block the premium hike or order its modification. Obama's legislative proposal on healthcare comes after legislation that would require all Americans to have insurance stalled in Congress amid Republican opposition. Republicans have criticised the Democratic legislation, saying it is too expensive at about $1-trillion over 10 years, that it unfairly forces people to obtain insurance, and that it would lead to a government takeover of healthcare. To sidestep Republican opposition, the Democrats may use a procedure called reconciliation, which would require just 51 Senate votes to pass. That may pose a problem because Senate rules require reconciliation to deal only with revenue and spending, which would mean the bill may have to be stripped down. House and Senate legislators were days away from overcoming differences when the January 19 special Senate election in Massachusetts deprived Democrats of the 60th vote they needed to get the new compromise through that chamber. Now, legislators are looking to Obama to finish the job.

Bloomberg, Reuters via Business Day, 23 February 2010

TESTING everyone at risk of HIV and treating them with antiretroviral drugs could eradicate the global epidemic within 40 years, according to the scientist at the centre of a radical new approach to fighting AIDS. An aggressive programme of prescribing antiretroviral treatment (ART) to every person infected with HIV could stop all new infections in five years and eventually wipe out the epidemic, Brian Williams of the South African Centre for Epidemiological Modelling and Analysis told the American Association for the Advancement of Science. Williams is part of a growing body of experts who believe anti-HIV drugs are probably the best hope of preventing and even eliminating the spread of AIDS, rather than waiting for the development of an effective vaccine or relying solely on people changing their sexual lifestyle. The idea will be tested in the coming year, with the start of the first properly controlled clinical trial involving thousands of people living in Hlabisa in Somkhele, about 220km north of Durban. Williams said this would be followed by similar trials in the United States, where HIV is rampant in some inner-city communities. He said the immediate best hope was to use ART not only to save lives but also to reduce transmission of HIV. ART drugs could effectively stop transmission within five years, he said, adding that it might be possible to stop HIV transmission and halve AIDS-related TB within 10 years and eliminate both within 40 years. Antiretroviral drugs dramatically lower the concentration of HIV in a person's bloodstream, and, in addition to protecting patients against AIDS, they significantly lower an individual's infectiousness. Williams believes that, if enough infected people were treated, it would lower the rate of infection to such an extent that the epidemic would die out within the lifetime of those undergoing the treatment. He said the problem was that the drugs were being used to save lives, but not to stop transmission. Blocking transmission could only be done with an extensive testing regime followed by rapid treatment with antiretroviral drugs to everyone found to be HIV positive. Williams said the concentration of the virus dropped 10 000 times with ART, which probably translated into a 25-fold reduction in infectiousness. But if this was done, it would be enough essentially to stop transmission. A 2008 study showed it was possible to cut new HIV cases by 95 percent, from 20 per 1 000 to one per 1 000, within 10 years of implementing a programme of universal testing and prescription of ART drugs. The drugs have to be taken daily for life, and the cost for South Africa alone would be about $4bn (almost R30bn) a year. But the cost of having to treat a growing number of AIDS patients, as well as the economic cost of young adults dying off, would be higher than giving out free ART drugs to everyone who needed them.

Steve Connor: The Independent via The Cape Times, 23 February 2010

THE SA National Blood Service (SANBS) has, as of February 1, mandated private healthcare institutions to ensure proof of payment from non-medical aid patients before the blood is administered. In a notice issued to private sector healthcare providers last year, the blood service said it was struggling to recoup payment from private paying patients for blood products and that the non-payment for blood, blood products and services was making it "impossible for the SANBS to continue providing adequate and safe blood in a sustainable manner". According to the memo, private healthcare practitioners will be required to "ensure proof of payment prior to the submission of blood products request forms to hospital blood banks for all non-emergency cases". The memo said that patients who were unable to pay privately and were not on medical aid schemes were requested to approach public hospitals. While the up front payment does not apply to emergency cases, Lenmed Clinic casualty department head Dr Yusuf Cassim said the mandate was "contradictory" in that, by virtue of requiring blood, it could be argued that the patient was in some sort of emergency. He said his department had taken the stance that no patient will be denied blood. He questioned why the blood service would charge for blood that it received for free.

Paediatric surgeon Professor Peter Beale said the new mandate was "fair enough" as long as patients in need of life-saving blood transfusions were not denied access to blood.

Thandi Skade: The Star, 23 February 2010