Laura du Preez: Business Report,

THE survival of the multi-billion-rand private medical scheme industry is under severe threat in its current form as the government looks for a way to resuscitate both an ailing public healthcare system and an increasingly unaffordable private healthcare system.

There are few details of the government's final intentions but the indications are clear that your healthcare cover is unlikely to continue in its current form.

Manto Tshabalala-Msimang, the Minister of Health, announced at a medical scheme conference on Monday that there is an urgent need for "momentous changes in healthcare financing" in South Africa.

Tshabalala-Msimang said she would present proposals for a national health insurance system to the cabinet this week.

But consumers, medical schemes, hospitals, doctors and other healthcare providers are all in the dark when it comes to how such a health insurance system might operate, despite much discussion of the matter at this week's annual Board of Healthcare Funders (BHF) conference in Durban.

Slindile Khanyile: Business Report,

MEDICAL aid schemes were losing millions of rands in undisclosed rebates and discounts, which healthcare providers kept for themselves, Rajesh Patel, the head of benefit risk at the Board of Healthcare Funders (BHF), said this week.

Patel said in the past 12 months healthcare providers, excluding hospital groups, charged medical aid schemes hidden costs of up to R1 billion.

This was because healthcare providers who sold services and products were using the rebate inclusive price instead of the net acquisition price, Patel said. Equipment companies were also not charging the true wholesale price.

"Device companies need to explain, and we need more transparency of these costs.

"There are 48 items that have increased while only 5.8 percent had decreased. The rebate inclusive price business outside hospitals has not been addressed," said Patel.

The Department of Health has introduced guidelines for billing which are voluntary. Anban Pillay, the department's chief director for economic cluster, said it was clear that they had to introduce regulation because not all parties were adhering to the

Pillay said that the Medicines and Related Substances Amendment Bill before parliament would make rebates illegal and everything would have to be sold at the net price. There would also be device regulation "because we are not sure where these rebates and discounts are going to".

Last year Patel accused private hospitals of overcharging medical aid schemes and their members by at least R2 billion a year. He claimed that hospitals were getting vendors to inflate invoices and then received off-invoice discounts or rebates that schemes were not aware of.

The hospital sector is dominated by three groups. Netcare removed the rebates on anaesthetic gases while Patel had to apologise to Life Healthcare and Medi-Clinic who were not using the discount model.

Shortly after that the BHF lodged a formal complaint to the consumer affairs council within the department of trade and industry to conduct an investigation into the matter.

Patel said the council should speed up the investigation and declare the practice illegal, which would lead to an immediate abolishment.

He said that theatre drapes and protection items had fallen by 10.9 percent and 19.4 percent, respectively.

Editorial Comment: The Cape Times,

MEDICAL scheme members in South Africa are apparently paying through their blocked noses for administration and other costs not related to their treatment. Quoting figures from the Council for Medical Schemes, University of Stellenbosch academic Heather McLeod pointed out this week at a Board of Healthcare Funders (BHF) conference in Durban that these are the highest costs of their kind in the world. Costs not related to treatment include costs of administration and reinsurance, broker fees, bad debt and trustee remuneration. These make up between 14% and 15% of the annual R60 billion spent by medical schemes. On average, each medical scheme member paid R240 a month to cover just these costs in 2006. Among the questions raised by the costs debate is the role of the country's 9 000 or so brokers. Whether or not their fees should be paid by scheme members is a controversial issue recently raised by Health Minister Manto Tshabalala-Msimang, currently on a mission into private healthcare. The role of administrators is also worth scrutinising. The interests of administrators - which can be JSE-listed companies - are not always aligned with those of the members of the schemes they manage. Nor are medical scheme members safe from the profiteering of unscrupulous health professionals and private hospitals. Earlier this year, the BHF launched an investigation into the practices of 10 of the country's 90 brain specialists who had claimed 40% of the R50 million spent by medical scheme members on neurology over two years, though they had seen only 25% of patients. And the Council for Medical Schemes has had to fight private hospitals to stop them pumping up prices for key materials and anaesthesia gases, only to find them trying to compensate for their lost income through huge increases in ward and theatre fees. All in all, it seems, medical scheme members have plenty to feel sick about.

SAPA,

KWAZULU-Natal Finance MEC Zweli Mkhize has said that the proposed National Health Insurance Bill was not an attempt to rid the country of the private health sector. Delivering the closing address at the Conference of the Board of Healthcare Funders in Durban, Mkhize said the challenge was to try and create a particular kind of partnership between private and government sectors which would ultimately improve health resources across the spectrum. Abolishing private healthcare was not the way the country wished to move, said Mkhize who is also a National Executive Council member in the ruling African National Congress. He said the African National Congress' Polokwane conference at the end of 2007 had looked back at what had been achieved and "the gaps" of the past 15 years. He said that looking at the United Nations millennium development goals, the ANC did not think the country was doing very well and did not believe that SA would be able to achieve those targets. Mkhize pointed to rising infant mortality rates as well as incidents of tuberculosis, including the drug resistant strains. Public institutions were faced with a loss of staff from public hospitals due to immigration as well as movement into the private sector. Mkhize, who was the KZN health MEC between 1994 and 2004, said the increasing costs within the private health sector as well as the declining percentage of the population covered by the private health sector were a concern. Further investment was needed in health infrastructure, especially public facilities, so that they would be able to compete with the private sector. Mkhize told delegates that the NHI was not about a socialist ideology, but rather a simple matter of affordability. He concluded by saying he would like to see more people in lower income brackets being covered by medical aid schemes.

Tamar Kahn: Business Day,

STRATEGIES for tackling the soaring costs of private healthcare topped the agenda yesterday at the annual Board of Healthcare Funders (BHF) conference, with medical scheme administrator Discovery Health describing how its managed care initiatives were saving schemes millions of rands a year. Discovery Health is a subsidiary of JSE-listed health and insurance company Discovery Holdings, and provides administration services to SA's biggest medical scheme, Discovery and 11 smaller schemes, which together cover 2,1-million beneficiaries. The term "managed care" is used to describe attempts to reduce unnecessary or inefficient healthcare expenditure. Discovery Health had taken steps to reduce unnecessary hospital admissions, negotiated with pharmaceutical companies to lower the price of medicines, and tightened up its oversight of the consumables used in hospitals, said the company's GM for strategic risk management, Jonathan Broomberg.

Slindile Khanyile:

MEDICAL aid scheme members in South Africa paid the highest non-healthcare costs in the world, according to Heather McLeod, a professor at the department of statistics and actuarial science at the University of Stellenbosch. McLeod, who delivered a paper at the annual conference of the Board of Healthcare Funders, said these costs made up between 14 percent and 15 percent of medical aids' R60 billion of annual expenditure. This was because of the artificial distinction between schemes and administrators, she said. The country that came closest was Germany at 8 percent, and most countries that have social insurance were sitting at about 2 percent, she said, adding that something as high as 14 percent or 15 percent was the highest in the world.

SLINDILE KHANYILE

Durban - Fourteen years after it was first mooted, the national health insurance scheme appears to be moving towards implementation. Some of the policy documents formulated over the past decade will be tabled before the cabinet tomorrow.

Health minister Manto Tshabalala-Msimang said yesterday that once the process was completed in the cabinet, costing would follow and the matter would be referred for public comment.

She told delegates at the opening of the Board of Healthcare Funders annual conference that the process had not moved as quickly as the department would have liked.

Slindile Khanyile: Business Report,

STEVEN Friedman, director of the Centre for the Study of Democracy at the University of Johannesburg, said yesterday that there were serious problems with the current medical aid system in South Africa, which was both morally and economically unsustainable. Addressing the Board of Healthcare Funders (BHF) conference, Friedman said the country did not have a system that was able to adequately provide healthcare to millions of its citizens. He said South Africa had not created a free market where people were able to make the right choices because the industry was not simplified. Friedman said medical aids were not interested in people, but rather the bottom line, adding that he most disempowering tool of the medical aid was that it was impossible to make a choice on information provided. Responding to Friedman's criticism, Humphrey Zokufa, the managing director of the BHF, said: "We have to listen and don't dismiss what he said. As an industry, we assume what we are doing is right. It's a wake-up call for us, as we move forward."

Tamar Kahn: Business Day,
Slindile Khanyile: Business Report,

HEALTH Minister Manto Tshabalala-Msimang will present her department's new policy on national health insurance (NHI) to the cabinet tomorrow. The African National Congress (ANC) has been debating NHI for over a decade, but the project received new impetus last year when the party's conference in Polokwane identified it as a priority. The government hopes to resolve the myriad problems facing both the public and private healthcare sectors in SA by introducing a new health system that will provide basic medical care to all citizens, with the rich subsidising the poor and the healthy subsidising the sick. It will be financed by a mixture of government funds and mandatory contributions from employees. Tshabalala-Msimang declined to provide details of the NHI policy, but did indicate that it had yet to be costed. The policy would be made available for public comment once it had been approved by the cabinet, she said. Speaking on the sidelines of the annual Board of Healthcare Funders (BHF) conference, she said NHI was intended to make quality healthcare affordable to more South Africans, and to address rising costs. Addressing delegates she said the private health sector had faced an "uncontrollable" cost spiral since the 1980s and was unsustainable in its current form. The most important cost drivers were private hospitals, specialists and administrative costs, she said. Annual expenditure on private hospitals was R803 per medical scheme beneficiary in 1997, which increased to R2 230 in 2005. Medical scheme contributions too had been increasing from an average of R3 423 per beneficiary in 1998 to R7 807 in 2005 and had become increasingly unaffordable, she said. Tshabalala-Msimang said some of the legislation required to support the implementation of NHI had already been developed, including the Medical Schemes Act, the National Health Act, and price regulation for medicines. Further amendments to support NHI were in the pipeline, most notably changes to the National Health Act that will pave the way for the government to oversee annual tariff negotiations between medical schemes and healthcare providers. Health economist Di McIntyre described to delegates the growing gap between the amount of money spent on patients using the public and private healthcare sectors, one of the reasons why the government is keen to implement NHI. Public spending on health per capita had "flat-lined" in real terms over the past decade, she said, hovering just below R1 000. She said it had just been keeping pace with population growth and inflation, yet the demands had increased dramatically, largely because of AIDS. Private healthcare spending per capita had increased 50%, from about R4 000 to R6 000 between 1998 and 2005, she said. At the same time, growing unemployment and the rising cost of medical scheme membership had reduced the proportion of the population able to afford cover to 14%, from 20% a decade ago. Moremi Nkosi, the director for health insurance in the Health Department, said the scheme could play three roles - as substitute, complementary or supplementary cover - but the details were still being discussed. Nkosi said there were no deadlines yet because the department did not want to rush and make mistakes. Another issue that was still being debated was how the scheme would be funded. Nkosi said another issue that' had to be considered was the responsibility for collecting the funds. He said a single-payer system would mean that the government would be responsible for pooling the funds, while the schemes played a significant role. By contrast, the multipayer system would put the bulk of the job into the private sector's hands.

Shaun Harris

Durban - The private healthcare industry, with private hospitals and specialists at the top of the hit list, have known further government regulation is on its way.
Health Minister Manto Tshabalala-Msimang removed any doubt about that on Monday morning - the private sector will be regulated.

Tshabalala-Msimang was opening the Board of Healthcare Funders conference in Durban. While further regulation seems inevitable, with the minister saying the general consensus at the Indaba she convened last September was "that government needs to regulate the private sector to ensure transparency in pricing", Tshabalala-Msimang denied proposed legislation would see her setting tariffs in the industry.

Laura du Preez: Personal Finance,

MEDICAL schemes are consolidating - and smaller schemes and restricted schemes for the likes of employer groups, in particular, are disappearing in liquidations and amalgamations.

This is according to a survey of medical scheme trends prepared by the office of the Registrar of Medical Schemes. The survey looked at medical scheme data for the five years between 2002 and 2006, during which period the number of schemes dwindled from 143 to 124 - a decline of 13.3 percent.

This was despite an overall increase of 3.9 percent in the membership of schemes.

"The decline was more pronounced in restricted as opposed to open schemes," the report says, noting that over the five-year period eight open schemes disappeared, leaving 41 open schemes in operation at the end of 2006.

Eleven restricted schemes closed over this period, bringing down the number of restricted schemes from 94 in 2002 to 83 in 2006.

The registrar's office categorised schemes as small (less than 6 000 members), medium (6 000 members to 30 000 beneficiaries) and large (more than 30 000 beneficiaries). It found that in 2002 more than half of the schemes were small (56.2 percent), 16.4 percent were medium and 27.4 percent were large.

Most of the small schemes were restricted schemes (79.3 percent).

By 2006, only 46 percent of the remaining medical schemes were small schemes, 22.6 percent were medium-sized schemes and 30.6 percent were large.

Difficult to survive

The report confirms what many in the medical schemes industry already know: it is difficult for small schemes to survive.

The schemes that closed down or amalgamated cited the reasons for doing so as "low membership, poor long-term financial sustainability, low economies of scale and difficult trading conditions".

Schemes rely on the contributions of younger, healthier members to subsidise the costs of treating their older, sicker members, and it is easier to achieve this cross-subsidisation with greater membership numbers.

Restricted schemes tend to have more older members than open medical schemes, which, combined with their generally smaller sizes, puts them at greater risk of high claims.

The registrar's report notes that the average age of medical scheme beneficiaries increased over the five-year period reviewed from 31 years to 31.5 years.

When the age groups of beneficiaries of schemes are analysed, the report notes, the advancing age distribution of restricted schemes seems to have been more pronounced than that of open schemes. The number of pensioners who are members of medical schemes increased over the five-year period. In 2002, the pensioner ratio was 5.9 percent and by 2006 this had reached 6.3 percent.

Equalisation fund

The proposed Risk Equalisation Fund (REF) for medical schemes is expected to help smaller restricted schemes because it will introduce cross-subsidisation of the costs of providing certain minimum benefits across all schemes. So schemes with younger, healthier members will, through the REF, subsidise certain healthcare costs of schemes with older, sicker members.

Legislation to enable the REF to start functioning is likely to come before Parliament this year and then further regulations will still have to be promulgated. It is expected that the REF will come into operation only two years after the enabling legislation is in place.

In the meantime, more smaller restricted medical schemes are likely to disappear.

The amalgamation of BHP Billiton SA Medical Scheme, a restricted scheme with about 5 000 members, with Bonitas Medical Fund, a large open scheme, was recently approved by the Competition Commission.

Meanwhile, large schemes, such as Discovery Health Medical Scheme, continue to grow. Discovery now has 840 700 members and covers 1.9 million lives.

Discovery claims its size is now giving it a competitive edge when it comes to contributions.

The new Government Employees Medical Scheme (Gems) is also growing at a rapid rate, especially because the government is incentivising its members to join the scheme by offering employees who join Gems a better subsidy than the one it pays to employees who belong to other medical schemes.

At a recent symposium, Gems said its membership has reached more than 250 000, and that it covers more than 680 000 lives.

Laura du Preez: Personal Finance,

MEDICAL scheme beneficiaries' use of private hospitals declined over the five years to the end of 2006, but this had no positive effect on claims paid to hospitals per beneficiary, which showed a real increase over the same period. This is according to research released this week by the Council for Medical Schemes.

The research contradicts arguments by the Hospital Association of South Africa (Hasa) that an increase in the utilisation of services, rather than tariff increases, is driving up private hospital costs, which are, in turn, pushing up your medical scheme contributions.

The study also reveals that over the past five years there have been higher rates of increases in what medical schemes spend on your claims than there have been in members' contributions.

Average contributions increased by 34.7 percent over the five years from 2002 to 2006. The increase in real terms (after inflation) was 11.2 percent over the five-year period, or 2.7 percent a year.

Claims paid by schemes increased in real terms by 20.1 percent over the five-year period, or 4.7 percent a year, the report says.

Pressure from providers

The higher increase in claims despite the decline in the use of private hospitals is attributed to cost pressure from healthcare providers. Private hospital admissions are regarded as one of the major drivers of costs in medical schemes.

However, members' utilisation of specialists - another major source of costs for schemes - has increased, the report shows.

Patrick Matshidze, the head of the council's benefit management unit, says many specialists charge at rates that are three times as high as those in the guideline National Health Reference Price List tariffs.

The effect of the increase in members' use of specialists is an increase in your contributions, or, in some instances, reduced benefits or a limit on your access to these doctors' services, he says.

In a recent presentation to Parliament's portfolio committee on health, Hasa provided statistics from the three major private hospital groups that showed there had been a 13-percent increase in medical scheme hospital admissions between 2002 and 2006. It said admissions had increased from 920 000 medical scheme beneficiaries in 2002 to about 1.03 million in 2006.

But the Council for Medical Schemes's latest report on trends in medical scheme contributions, membership and benefits shows that in 2002 there were 231.6 beneficiaries in every 1 000 who were admitted to hospital. By 2006, this had dropped 25 percent to 173.7 beneficiaries for every 1 000. The number of beneficiaries admitted to day clinics also declined - by 29 percent - the Council for Medical Schemes's report says.

Annual expenditure on private hospitals per beneficiary in 2002 was R2 023.56 and it increased to R2 483.84 by 2006 - an increase of 22.85 percent in real (after-inflation) terms, the report says. Expenditure on ward and theatre fees increased consistently in real terms over the five years, with total real increases of 34 percent and 32.1 percent respectively.

Matshidze says the council's figures are based on schemes' audited financial statements. He says the council would like to see the hospitals' data to see what the differences are.

Matshidze says in an attempt to understand what is driving medical scheme costs, the council is also busy with research into the mix of hospital cases for which schemes paid and the variations in the prices paid for those cases.

An earlier report prepared by the office of the Registrar of Medical Schemes commented on data on the length of stays of private hospital users. It said this, when seen together with high (albeit declining) admission rates, indicates that patients who are not very ill are being admitted to hospital.

Fewer visits to dentists

An analysis of the five-year trends also showed that on average medical scheme members are claiming for fewer visits to general practitioners (GPs) and dentists than they were five years ago.

However, the number of beneficiaries who made at least one visit a year to a GP that was paid for by their scheme had increased.

In the case of dentists, there was both a decrease in the use of their services and a 28.3-percent decrease in claims paid to them per beneficiary in real terms.

The rate at which medical scheme members are using the services of pathologists, radiologists, physicians, paediatricians, gynaecologists and anaesthetists is described in the report as high in 2002, with the use of each speciality recorded at more than 100 visits a year for every 1 000 beneficiaries.

According to the report, by 2006 utilisation of the services of pathologists had increased by 33.7 percent, followed by paediatricians (16.6 percent) and physicians (14.7 percent).

The use of radiologists and anaesthetists increased by 7.4 percent and 0.9 percent respectively.

There was also a general increase in the amount that schemes spent on specialists, with expenditure on anaesthetists per beneficiary increasing by 89.3 percent over the five-year period, expenditure on pathologists increasing by 87 percent and expenditure on radiologists rising by 51.8 percent.

These trends were maintained when the figures were adjusted for inflation, the report says.

Matshidze says there are myriad factors that could be behind these trends, and the Council for Medical Schemes still has to investigate some of them further.

However, Matshidze says, the benefit structure of many medial schemes is such that you, as a member, can go straight to a specialist without seeing a GP for a referral first. It appears, he says, that many scheme members are going straight to specialists.
Matshidze says the council does not have a fuller understanding of why there has been such a steep increase in scheme members' use of radiologists and pathologists.

He says it is also difficult to say what is behind the decrease in members' claims for visits to dentists, because most schemes provide benefits for these services, although hospital plans and some low-cost schemes options do not.

Matshidze says certain changes during the five years to the end of 2006 - such as the introduction of cover for certain chronic conditions as benefits schemes must provide - will have affected schemes, but the impact of these changes was not the focus of this research.

Pat Sidley: Business Report,

THERE has been a good deal of celebrating over the Cape high court judgment stopping Matthias Rath from doing business in this country by selling drugs claimed to be a cure for AIDS.

The Treatment Action Campaign (TAC), with the SA Medical Association (Sama), has good reason to be delighted with the findings for the time being. It is just as well Health Minister Manto Tshabalala-Msimang is studying the judgment.

Apart from potentially making her feel a bit liverish (pun intended) where it knocks her specifically, it also has some problem areas that are likely to muddy the water in the medicines registration process - as well as the intended amended process.

She may not see this as a problem as, once again, her powers in the proposed amendment to the Medicines Act have been strengthened. The loopholes and gaps in the judgment present her with an opportunity to wield power one would rather not have vested in the hands of one politician.

Unfortunately, this particular administration has provided enough evidence of the fact that political interference in how medicines get to market and how people are treated can do great harm to the vulnerable.

The TAC had accused Rath of selling medication by using claims which could not be backed up for people with HIV/AIDS. The TAC was also worried about the use of the drugs in clinics in what looked like ethically and legally dubious clinical trials.

It was concerned, too, that a substance found in one of the products was scheduled, as this should have meant the drug had to be approved by the Medicines Control Council before finding its way onto the market.

The activists' biggest beef was that Tshabalala-Msimang was required to give effect to the law to ensure that false claims could not be made about medication; that safe and efficacious drugs made it onto the market; and that potentially harmful substances could not be sold without undergoing this process.

The process also involves checking that clinical trials (when humans are part of the testing process) are done in an ethical and legal way.

It is worth looking back at why most countries have a system of laws and bodies that ensure some kind of process to prevent unscrupulous players from making a quick buck at the expense of the health of the more vulnerable.

The landmark case that forced countries to put many of these measures in place was over a drug called Thalidomide, which was prescribed for pregnant women suffering from nausea. The unmentioned side effect of this drug was birth defects that destroyed many lives for several generations. Inevitably, the scrutiny fell on whether any clinical trial processes had been undertaken and if this catastrophe could have been anticipated.

As a result of the many court cases about the use of the drug, most countries beefed up their processes to prevent a recurrence, minimise a potential occurrence involving new drugs and ensure that the culprits would be found.

The US toughened the laws that control food and drug administration. These days the EU's very tough approval regime is being implemented, and in 1998 the South African government passed a new and hotly contested Medicines and Controlled Substances Act, aimed at making the processes rational.

Then the AIDS pandemic struck - but the government decided that the real problem was poverty. The government made many decisions and indecisions according to batty theories, and enormous pressure was brought to bear on regulatory authorities all over the world by AIDS activists and pharmaceutical companies to speed up the process that Thalidomide had slowed, in order to get new medication onto the market more quickly.

In the middle of the confused and confusing atmosphere of government battiness and activist and pharmaceutical company pressure, two snake oil salesmen tried to get Virodene - a lethal industrial solvent - onto the market by circumventing the process that would have stopped them and using politicians who should have known better.

Various heads rolled among those appointed to protect us from Thalidomide and snake oil salesmen, and registration of antiretroviral medication for treating AIDS became an intensely political issue with safety and efficacy further down the list of priorities. Various rules and regulations were changed to an extent that made health supplements the flavour of the week.

Virodene, Rath's vitamins (with added extras) and the Minister's beetroot and garlic gained a prominence and near-respectability in the treatment of HIV/AIDS.

That is the truncated background that prompted the TAC and the Sama to ask the court to force Tshabalala-Msimang to do her job of ensuring that only safe and efficacious medicine got into the market; stop illegal and unethical clinical trials; and stop the sale and distribution of the products that had caused concern to the TAC and Sama. This was done.

The judgment, however, has sections dealing with the registration of medication and the sale of scheduled substances, which some experts fear may confuse things if push should come to shove and court action becomes necessary again.

The judgment points to two "call-up notices", one in 1985 and one superseding it in 2002, that are apparently aimed at dealing with a potential requirement to register.

The judgment also mentions areas found to be contradictory in the 2002 notice. The differences involve how complementary medicines and similar substances are to be treated and how to determine what needs to be registered and what does not. They are not easy for a lay person to understand and, given some of the remarks made, experts are finding singular difficulty in dealing with these parts of the judgment.

To complicate this further, the amendments now before parliament will make a much larger and more complicated process out of registration, vest more power in the Health Minister and may be more complicated than intended when seen against the judgment.

According to the TAC's advocate, Geoff Budlender, the judgment has been very useful in stopping Rath from doing business in this country. But he says the parts of the judgment dealing with scheduled substances and registration may have made it more difficult to distinguish between processes in the future.

Andy Gray, a pharmacological expert from the University of KwaZulu-Natal, points to the powers of the Minister and questions whether the confusion in the judgment, along with the proposed new law, will cause the law to be less effective than it should.

An obvious question is whether this will all be used to keep particular medications off the market as and when a political need arises, or whether it will be used to force a substance onto the market for political reasons.

It needs to be cleared up and fought where necessary. This country does not need Virodene or Thalidomide.

Sick people should not be forced to drag themselves to court each time a politician decides a proven medicine should not be given - as was the case for Nevirapine, used to prevent HIV transmission from HIV-positive pregnant women to their soon-to-be-born babies.

Marion Heap: The Cape Times,

MARION Heap, of the School of Public Health and Family Medicine, argues that the language barrier excludes many patients, including the deaf, from proper healthcare.

In 2006 my friend Makhaya (not his real name) died.

At his funeral, I could not help wondering: would a professional South African Sign (SASL) interpreter service have made a difference?

It took a long time before Makhaya's brain tumour was diagnosed. He went to a number of healthcare facilities, private and public. Healthcare focused on the vomiting, sent him for X-rays, and gave him antacids and dietary advice. Without an interpreter, it was difficult for healthcare to take a proper history and probe symptoms.

Makhaya had no way to express himself. He could not explain that in addition to the vomiting, his headaches were severe, he was slurring his signs, his eyesight was failing and he was finding it difficult to walk in a straight line. In due course, he became very ill, worn out by the vomiting and the pain.

He was admitted to a district hospital, and from there he was transferred to an academic hospital. At the academic hospital, a brain tumour was diagnosed. An emergency shunt relieved the inter-cranial pressure and later the tumour was removed surgically.
The reprieve was only temporary though, and the tumour regrew. Makhaya eventually succumbed at a chronic care hospital. He was 54-years-old.

This year South Africa became one of the first countries to ratify the UN Convention on the Rights of Persons with Disabilities. This means that in compliance with Article 9 (1) (e) of the Convention, South Africa is obliged to provide, among other services, professional sign language interpreters to facilitate accessibility to buildings and other facilities open to the public. The challenge lies in putting this progressive policy into practice.

South Africa is recognised as having one of the most progressive constitutions and language policies worldwide (Neville Alexander, "Proper use of mother tongue is the key to success", Cape Times, April 21). The Constitution provides for the rights to equality (Section 9) and access to healthcare services (Section 27 (1) (a)). Read together, these provisions should guarantee access to non-discriminatory healthcare on the basis of equality.

The Constitution recognises 11 official languages. SASL is not recognised as an official language, but it has status. The Pan South African Language Board has been mandated by the Constitution (Chapter 1) to promote and create conditions for the development and use of SASL (and Khoi and Nama) in addition to the 11 official languages. Section 6 (2) of the National Health Act (No 61, 2003) states that the healthcare provider must inform the user (of the health services) in a language that the user understands, and in a manner that takes into account the user's level of literacy.

Thus, we have many rights - on paper - but language barriers continue to present formidable challenges to accessing appropriate healthcare services for many people.

In the public health sector, English and/or Afrikaans tend to be dominant among medical professionals, while the majority of the patients speak one or other indigenous language. Even the signage at some of Cape Town's public hospitals is still only in English and Afrikaans.

When signs are translated into Xhosa - usually unprofessionally - they are often so badly translated that they have been described as "meaningless and offensive".

For example: the one advising pregnant women to phone a clinic when they are in labour, translated as "phone the clinic when your tummy is running" (Weekend Argus, March 12, 2005).

To overcome language barriers and to ensure equal access to effective, non-discriminatory healthcare, advocate Karrisha Pillay has argued that professional (ie trained and accredited) interpreter and translation services must become an integral part of service delivery.

My chief concern is deaf people, whose first language is SASL. The professional interpreting needs of deaf people are urgent.

There are only six professional, accredited SASL interpreters for a population estimated at between 500 000 and 1.5 million people.

Professional interpreting services in healthcare in this country are and always have been lacking - despite the country's long history of plurilingualism. All the major language groups of the world, African (Bantu and Khoisan), Indo-European and Malayo-Polynesian were represented at the Cape a few years into South Africa's colonial era. Yet, outside of the judiciary, there were no official interpreter posts in the public service in all the years leading up to 1994. This trend continues in post-apartheid South Africa: a recent revision of the public service post structure makes no provision for official interpreter posts in healthcare.

Without interpreters, health professionals and patients struggle to address the language gap and communicate across language barriers. Nurses (already over-burdened by cost-cutting measures and staff shortages), often carry the interpreting load without extra remuneration - or training.

In South Africa, we take the language problem for granted and "make do". The result is that the challenge presented by linguistic diversity has become almost invisible. But the consequences and problems remain hidden.

Deaf people bring these problems to light. They are the "particular" case that challenges the routinised strategies. They do so because signed languages are similar to, but different from, spoken language. Signed languages have the same linguistic structure as that proposed for all other languages.

They are learnt in the same way as spoken language, and anything that is expressed in spoken language can be expressed in signed language. You can gossip, flirt, fall in and out of love, joke, skel, give a lecture, make poetry and even talk in your sleep. Signed languages are only different in that they are visual-gestural languages that use the modality of space. But this makes them "seem" very different. As such, they are the rule breakers, the exceptions that "prove the rule".

Our survey of the healthcare and communication experiences of deaf people in Cape Town identified problems such as delays in diagnosis, missed appointments, repeat visits, misdiagnosis, misunderstandings, misuse of medication, as well as anxiety and distress. Athalie Crawford has described similar problems for Xhosa-speaking patients trying to access healthcare without knowing the language - including the distress and anxiety.

It is time to take our rights seriously. This means a much greater emphasis on marginalised languages as well as on the training of interpreters and translators, professionalism, and accreditation.

Until professional interpreting services are an integral part of healthcare services, we will not bridge the language gap and a majority of South Africans will continue to be deprived of their constitutional right to healthcare.

Andrew Gillingham: Business Day,

ULTIMATELY, healthcare professionals determine whether beneficiaries of medical schemes receive best-value care and they should be at the centre of any health risk-management strategy.

Pieter Dorfling, divisional MD of Medscheme Health Risk Solutions, says healthcare professionals interact directly with medical scheme members. As such they are in the best position to influence what happens at the doctor-patient interface in terms of health risk-management objectives.

He says the first step in unlocking the potential of this dynamic lies in a collaborative approach between funders and providers of care. "For health risk-management to be taken to new levels, innovative solutions in collaboration with providers of care should complement current approaches."

He says that medical schemes strive to deliver the best value to their members for the premiums that they pay and most purchase a variety of health risk-management offerings to achieve these goals.
However, although these are important tools for managing healthcare expenditure, they have a finite ability to achieve the best possible care.

"There is huge potential for funders and healthcare professionals to work together to achieve best value for members. However, the adversarial relationship that commonly exists is not conducive to achieving this goal."

Explanations for this relationship tend to focus on inadequate tariffs and a perceived impact of managed-care interventions on professional autonomy and practice administration.

"Doctors are mandated to provide the best possible medical care for each individual patient without explicit consideration of the cost-effectiveness and affordability. On the other hand, medical schemes carry the responsibility for funding the delivery of care for an entire group of people while ensuring the financial viability of the fund.

"Clearly these are fundamentally differing perspectives that may easily result in providers and funders being at odds with one another. This is shortsighted, as the philosophy of providing best-value care to all patients is fundamentally identical.

"Sharing information with healthcare professionals should be seen as a true partnership to achieve the common objective of best value for patients and their medical schemes."

He says health risk-management is unlikely to evolve to a new level without the positive participation of healthcare professionals.