Draft: Primary Health Care Services

11/27/2019

DRAFT: PRIMARY HEALTH CARE SERVICES

COUNCIL FOR MEDICAL SCHEMES

Disclaimer

The proposed set of services and interventions are a first step towards defining services that should be available in a primary health care setting. It should be noted that at this stage, these proposals comprise inputs by different stakeholders and do not represent the final views of the PMB Review Advisory Committee.

Page 1 of 109

Acknowledgements This draft document is the culmination of a task that has involved many stakeholders. It benefitted greatly from ideas, inputs and review from a broad range of participation from providers, academia, funders, professional bodies and consumers.

A special thanks to the PMB Review Advisory Committee for providing guidance on the review of the PMBs.

A special tribute is paid to the clinical experts who contributed their time and experience to review the proposed package. Without their contributions, the Council for Medical Schemes would not have achieved this important milestone.

The project was co-ordinated for the Council for Medical Schemes, by the Clinical Unit.

Page 2 of 109

Abbreviations

AIDS Acquired Immune Deficiency Syndrome CMS Council for Medical Schemes DALYs Disability Adjusted Life Years DCSTs District Specialist Teams DTPs Diagnosis Treatment Pairs EPI Expanded Program on Immunisation GDP Gross Domestic Product HIV Human Immunodeficiency Virus MCDA Multiple Criteria Decision Analysis MDGs Millennium Developmental Goals MDT Multi-Disciplinary Teams MMSE Mini-Mental State Examination

MOCA Montreal Cognitive Assessment NDP National Developmental Plan NDoH National Department of Health NHI National Health Insurance NPC National Planning Commission PHC Primary Health Care PMBs Prescribed Minimum Benefits SDGs Sustainable Development Goals StatsSA Statistics South Africa TB Tuberculosis UHC Universal Health Coverage

Page 3 of 109

Table of Contents Disclaimer ...... 1 Acknowledgements ...... 2 Abbreviations ...... 3 1. Introduction ...... 5 2. Background ...... 6 3. Policy and Legislative Mandate ...... 6 5. Guiding Principles ...... 11 6. Process of developing the PHC package ...... 11 7. Proposed Primary Health Care Services...... 12 8. Preventative Services ...... 14 9. Diagnostic services ...... 23 9.1 Pathology Services ...... 23 9.2 Radiological Services ...... 29 10. Treatment and management of acute and chronic conditions ...... 35 10.1 Essential Medicine List ...... 35 10.2 Medical and Surgical Management ...... 48 10.3 Assistive Devices and consumables ...... 77 11. Rehabilitation ...... 80 12. Palliative Care...... 90 13. Way Forward...... 93 14. References ...... 94 ANNEXURE A: PRINCIPLES AND METHODS FOR PRIORITY SETTING TO GUIDE THE PMB REVIEW PROCESS ...... 97 ANNEXURE B: PROCESS FOR REVIEWING THE PACKAGE...... 103

Page 4 of 109

1. Introduction 1. The fundamental aim of any health system is to prevent disease and reduce ill-health to ensure that people remain as healthy as possible, for as long as possible. 2. The prescribed minimum benefits (PMBs) is a list of minimum benefits that medical schemes must provide to members irrespective of the benefit option that members belong to. Many stakeholders have commented that the current PMBs are not responsive enough to the changes in healthcare needs of the population; current health technology and best clinical practice; burden of disease; health policy; as well as the financial impact on medical schemes. 3. Following the previous review conducted on the PMBs, the Council for Medical Schemes (CMS) made submissions to the National Department of Health (NDoH) for the review of the PMBs based on inputs from various committees and other stakeholders. The feedback from the NDoH was that the current package does not prioritise primary health care (PHC) and does not address the needs of the country. 4. Primary health care is defined as essential health care made accessible at a cost a country and community can afford, with methods that are practical, scientifically sound and socially acceptable. This approach is organised to reduce exclusion and social disparities in the provision and access to health services; is people- centred; intersectoral; collaborative; and promotes the participation of all stakeholders (Alma Ata Declaration, 1978). 5. The current review process is aimed at addressing the issues raised, considering the submissions that were previously made. 6. The goal of this review is therefore to define a comprehensive PHC services with emphasis on the following; • Alignment of the PMB package with developments in health policy. • Specification of a comprehensive set of essential healthcare services. • Identification of actions that should be undertaken to ensure the sustainability of the package. • Identification of measures required to ensure affordability of the new package.

7. The document is a first attempt to develop a service based primary health care package for medical schemes. The CMS together with the different PMB review committees will appreciate any input to the sections that follow, as well as any other aspect not covered in this document. The document is organised as follows: 1) Introduction; 2) Background; 3) Policy and legislative mandates; 4) The context of health and disease in South Africa; 5) Guiding principles; 6) The process of developing the package; 7) The proposed Primary Health Care package.

Page 5 of 109

2. Background 8. The process of reviewing the prescribed minimum benefits was initiated through circular 83 of 2016 whereby the CMS outlined its views with regards to the review of the PMBs. Several stakeholder meetings were held in 2017 to ensure that there is a better understanding by all stakeholders regarding how the review process will unfold; and to get inputs and suggestions regarding the initiative, as well as to make nominations for stakeholders’ representatives for the different committees. 9. Three main functional committees were established; the PMB review advisory committee, the costing committee and the legal & regulatory committee with stakeholders from medical schemes, administrators and hospitals. A steering committee was also established in order to ensure consistency with national policy. 10. Between 2017 and 2019, several meetings were held by the committees in order to advise on the way forward with regards to the review of the PMBs. These meetings culminated into a discussion document on priority setting, and process for the development of the PMB package. The following processes were proposed; • Identifying specific preventive services using the recommended principles. • Identifying and reviewing the current primary care benefits included in the PMB package. • Undertaking a substantive review of the PMB package using Multi criteria decision analysis (MCDA). 11. Following the Advisory Committee meeting on 24th January 2019, meetings we held to identify preventive services and the primary healthcare services. 3. Policy and Legislative Mandate 12. The Medical Schemes Act, (Act No.131 of 1998) introduced PMBs as a policy instrument for defining minimum allowable levels of benefits to be covered by medical schemes. Regulations made in terms of the Act were promulgated on 20 October 1999 and came into effect on 1 January 2000. Annexure A to the Regulations defines the PMBs in terms of a positive list of 270 diagnosis and treatment pairs (DTPs) that must be provided by each medical scheme, without financial limits in at least one provider setting. The currently applicable legislation is shown in Appendix B of the Medical Schemes Act. 13. The NDoH is required to monitor the impact, effectiveness and appropriateness of the PMB provisions. A review is to be conducted at least every two years by the NDoH. These reviews are to provide recommendations for the revision of the PMBs on the basis of: (i) inconsistencies or flaws in the current regulations; (ii) the cost-effectiveness of health technologies or interventions; (iii) consistency with developments in the health policy; and (iv) the impact on medical scheme viability and its affordability to members.

Page 6 of 109

14. Since the promulgation of these Regulations, several developments have been observed, that is, considerable developments in the management of several conditions; some level of inconsistencies and flaws identified in the current regulations; as well as changes in the cost-effectiveness of health technologies or interventions. The NDoH has also published the National Health Insurance (NHI) and Medical Schemes Amendment Bills. 15. The aim of the NHI Bill was to align the current Medical Schemes Act and the NHI. The NHI embraces the goal of Universal health coverage (UHC) and seeks to provide quality health services to all South Africans, ensuring that access to health does not result in catastrophic expenditures. The philosophy of primary healthcare forms the basis of South Africa’s health policy and provides guidance for healthcare service delivery in South Africa. 16. Various national legislative and policy framework support the provision of primary healthcare services. This primary health care package is based on and is consistent with several existing policy and legislation mandates in South Africa. These include: • The Constitution of the Republic of South Africa, 1996 • The National Health Act (Act No. 61 of 2003) • The Mental Health Act (Act No. 17 of 2002) • The National Development Plan, Vision 2030 • National Mental Health Policy Framework and Strategic Plan, 2013 – 2020 • The National Department of Health Strategic Goals • National HIV testing services, 2016 • National Infection Prevention and Control Policy & Strategy, 2007 • National Policy Framework and Strategy on Palliative Care 2017 -2022 • Framework and Strategy for Disability and Rehabilitation Services in South Africa 2015-2020 17. South Africa is also signatory to several resolutions that aim to reduce the burden of communicable and non- communicable diseases. These include: • Resolutions of the World Health Assembly (WHA) 53.17 on the Prevention and control of noncommunicable diseases (NCDs) and 61.14 on the Prevention and control of non- communicable diseases; • Sustainable Development Goal 3 (SDG 3) which aims to ensure healthy lives and promote well- being for all at all ages; to improve maternal and child health outcomes, end infectious diseases, reduce premature mortality from non-communicable diseases and injuries, and ensure universal health coverage by 2030.

Page 7 of 109

• The implementation of the global strategy on non-communicable Diseases; • The report of the World Health Organisation (WHO) Commission on Social Determinants of Health (2008); • The Nairobi Call to Action for Health Promotion (2009); • Africa Health Strategy: 2007 -2015 • The Mauritius Call for Action on Diabetes, Cardiovascular Diseases and Non-Communicable Diseases (2009); 5.6.7 • WHO Framework Convention on Tobacco Control (FCTC-2003); • The Action Plan for the Global Strategy for the Prevention and Control of Non-Communicable Diseases; • The Global Strategy on Diet, Physical Activity and Health and other relevant international strategies to address Non-Communicable Diseases; • Resolution on Diet, Physical Activity and Health (WHA 55.23); • The African Union’s Campaign for the Accelerated Reduction of Maternal, Neonatal and Child Mortality in Africa; • African Union’s Agenda 2063 which envisages a continent characterised by universal access to healthcare, zero communicable deaths, zero maternal deaths, zero child deaths and countries capable of mobilising domestic funding for preventing, detecting and responding to public health threats such as noncommunicable diseases, health needs of the youth population and malnutrition by 2063.

4. Context of Health and Disease in South Africa

18. South Africa faces a quadruple burden of diseases, namely; a very high prevalence of Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) which has now entered a synergistic relationship with Tuberculosis (TB); increased maternal and child morbidity and mortality; exploding prevalence of non-communicable diseases mostly driven by risk factors related to life-style; and violence, injuries and trauma (1). 19. South Africa is also one of the countries with the highest burden of TB, with the WHO statistics giving an estimated incidence of 53 969 cases of active TB in 2014. Out of the 450,000 incidents in South Africa, it is estimated by WHO that about 270,000 (60%) of the people have both HIV and TB infection (WHO, 2014). The estimated overall HIV prevalence rate is approximately 13.1% of the total South African population. The

Page 8 of 109

total number of people living with HIV was estimated at approximately 7.52 million in 2018. For adults aged 15–49 years, an estimated 19% of the population is HIV positive(2) 20. In 2011, maternal mortality rate was estimated at 197 per 100 000 which was far higher than the Millennium Development Goal (MDG) target of 38 per 100 000 live births by 2015. The infant mortality rate for 2018 was estimated at 36,4 per 1 000 live births(2). 21. Non- communicable diseases (NCDs) are also an issue of concern globally. According to the WHO, NCDs accounted for 51%% of all deaths in South Africa in 2018, – 19% of these were due to cardiovascular disease and cancers(3). In the medical scheme environment, hypertension was the most prevalent condition at 143 per 1000 beneficiaries in 2018(4). 22. Mental health is also becoming an issue of concern in South Africa. According to the South African Stress and Health Survey, the 12-month prevalence of common mental disorders among SA adults was 16.5% in 2004(5). 23. Mental illnesses present themselves through clusters of symptoms, or illness experiences. These symptoms, or experiences, are associated with significant distress and impairment in one or more domains of human functioning such as learning, working or family relationships, defined as clinically significant mental disorders. 24. The relationship between HIV, NCDs, disorders during the perinatal period, substance abuse, and the experience of trauma and mental health disorder has been established. According to Myer, et.al (2008), depression, anxiety and stressful life events are associated with a worsened course of illness among those who are HIV positive. In a study conducted in Cape Town, 19% of those attending routine HIV follow-up care had depression, post-traumatic stress disorder and alcohol dependence. 25. A similar relationship has been observed between NCDs and mental illness. Depression and anxiety have been shown to increase the risk of hypertension. In addition, depression has been shown to be an independent risk factor for stroke and type 2 diabetes. 26. Mental disorders during pregnancy and the postpartum period have also been associated with increased maternal morbidity and mortality and adverse child health outcomes. Meintjies, et.al (2015) indicate that a large proportion of pregnant women in Cape Town had multiple risk factors for adverse perinatal outcomes, including depression and alcohol abuse(6). 27. Mental disorders represent not only an immense psychological, social, and increased risk for physical illness, but also an economic burden to society. According to Lund, et.al (2013), government spends 2.2% of its annual gross domestic product (GDP) on treatment of mental disorders(7). Neuropsychiatric conditions account for 13% of the total Disability Adjusted Life Years (DALYs) lost due to all diseases and injuries in the world and are estimated to increase to 15% by 2020. Substance abuse has also been identified as a risk factor for mental illness and injuries. The rate of injury in South Africa is 158 per 100 000 population. Road traffic accidents and interpersonal violence are shown to be the leading causes of Years of Life Lost.

Page 9 of 109

28. The National Development Plan (NDP) envisions a life expectancy of at least 70 years; a largely HIV-free population below 20 years; 28% reduction in NDCs; 50% reduction in injuries, accidents and violence; infant mortality rate less than 20 per 1 000 live births; under-five mortality rate less than 30 per 1 000 live births; maternal mortality rate less than 100 per 100 000 live births; and combating the tuberculosis and HIV/AIDS epidemics by 2030 (National Planning Commission [NPC], 2011).

Table 1: Leading cause of death in South Africa

Causes of death (based on ICD- 2014 2015 2016 10) Rank Number % Rank Number % Rank Number %

Tuberculosis (A15-A19) 1 39 695 8.3 1 34 042 7.2 1 29 513 6.5

Diabetes(E10-E14) 2 24 092 5.1 2 25 774 5.4 2 25 255 5.5

Other forms of heart diseases(130- 3 23 009 4.8 4 23 299 4.9 3 23 515 5.1 I152)

Cerebrovascular diseases (I60-I69) 4 24 258 5.1 3 23 505 5.0 4 23 137 5.1

Human immunodeficiency virus [HIV] 5 22 866 4.8 5 22 557 4.8 5 21 830 4.8 B20-B24

Hypertensive diseases (I10-I15) 6 18 146 3.9 7 19 845 4.2 6 19 960 4.4

Influenza and pneumonia (J09-J18) 7 22 876 4.8 6 21 001 4.4 7 19 638 4.3

Other viral diseases (B25-B34) 8 14 574 3.1 8 16 475 3.5 8 16 577 3.6

Ischemic heart disease (I20-I25) … 10 12 714 2.7 9 12 883 2.8

Chronic lower respiratory disease (J40- 10 12 793 2.7 9 13 006 2.7 10 12 659 2.8 J47)

Intestinal infectious disease (A00-A09) 8 14 834 3.1 … … … … … …

Other natural diseases 208 537 43.7 207 820 43.9 200 403 43.9

Non-natural diseases 50 939 10.7 53 228 11.2 51 242 11.2

All causes 476 891 100.0 473 266 100.0 456 612 100.0

Source: Statistics South Africa

Page 10 of 109

5. Guiding Principles 29. The criterion for selecting the healthcare package draws on recommendations made by the Priority Setting Sub-committee. The committee recommends that the selection of the new package should be based on the health needs, right to access health care services, financial risk protection, affordability and sustainability, clinical- and cost-effectiveness, as well as efficiency. i. Health needs: the proposed services should address the health needs of the country. ii. Right to access health care services: the proposed principles should address the needs of the most vulnerable. iii. Financial risk protection: Those in need should have access to all necessary quality health services without financial hardship. iv. Affordability and sustainability: the proposed services should be affordable to members and not jeopardise members’ ability to pay for medical schemes. The sustainability of the medical scheme should also not be jeopardised. v. Clinical and Cost effectiveness: proposed interventions should be clinically effective and cost- effective. vi. Efficiency: healthcare resources should be used to get the best value for money.

6. Process of developing the PHC package 30. Figure 1 outlines the process followed to define the primary health care package. Phase I entailed identifying services from different stakeholders by the CMS. Phase II of the process entailed reviewing of the identified services by the technical sub-committee. The technical sub-committee consisted mostly of a multidisciplinary team comprising stakeholders from academia and provider groups. Meetings were scheduled between the months of February and October 2019 to review services identified in phase I of the process. The following meetings took place:

• Preventive services • Maternal and Neonatal services • Child health services • Mental health services • Oral and Eye Health Services • Radiology and Pathology Services • Rehabilitation services • Medical and Surgical procedure

Page 11 of 109

• Essential drugs, Devices and Consumables • Palliative services

31. Based on the recommendation of the priority setting sub-committee, it was agreed at the first meeting of the technical sub-committees that the PHC package will include services that are essential and supported by level A and B evidence. Where evidence A and B could not be established during the meeting proceedings, committee members were advised to gather such evidence and send it to the project team. The committees further agreed that services that are currently in national policy should be included up to the district level of care as defined in the public sector. According to the Department of Health, district hospitals play a pivotal role in supporting primary health care on the one hand and being a gateway to more specialist care on the other. WHO states that district hospitals should provide diagnostic, treatment, care, counselling and rehabilitation services.

• Identify primary health care services in the current PMBs • Identify primary health care services covered by schemes • Identify primary health care services offered by NDoH • Identify primary health care services proposed under NHI PhaseI • Identify primary health care services proposed by stakeholders

• Review identified primary health care • Gather evidence about interventions • Elicit inputs from stakeholders PhaseII • Publish for stakeholder comments

• Costing of proposed services • Prioritisattion of services • Appraisal of services by the PMB Review Advisory Committee • Publish final output PhaseIII • Submit costed package

Figure1: Primary health care package review process 7. Proposed Primary Health Care Services 32. Primary health care is defined as "essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and the country can afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination(8)." 33. PHC is a whole-of-society approach to health that aims to ensure the highest possible level of health and wellbeing through three components; • Primary care and essential public health functions as the core of integrated health services;

Page 12 of 109

• Multi-sectoral policy and action; and • Empowered people and communities 34. Primary care broadly refers to day-to-day healthcare given by a health care provider. Typically, a nurse practitioner or generalist practitioner acts as the first point of contact and as the principal for continuing care for patients within a healthcare system. Furthermore, this provider is expected to coordinate other specialist care that the patient may need. A detailed definition of primary care provides a specific description of the nature of services to be provided; identifies service providers; the settings and the systems for providing this care. i. The care provided to the patient 35. Primary care services are organized to meet the needs of patients with undifferentiated problems. The vast majority of patient concerns and needs ought to be addressed in the primary care practice itself. These services include health promotion, disease prevention, health maintenance, counselling, patient education, diagnosis and treatment of acute and chronic illnesses, rehabilitation and palliative care in a variety of health care settings. Therefore, the bulk of services in the basket of primary care would be simple, uncomplicated, and largely manageable by the available (suited) practitioners in these settings. ii. The setting of primary care 36. While the settings for primary care are variable, they are generally health care practices which are located in the community closest to the patients. These facilities enable access to health care while maintaining a wide variety of specialty and institutional consultative and referral relationships for specific care needs. Other areas of care that are used for primary care include inpatient services, critical care, long-term care, home care, day care, etc. iii. The system of providing primary care 37. Primary care provides patient advocacy in the healthcare system to accomplish cost-effective, efficient and comprehensive care by coordination of health care services. Primary care promotes effective communication with patients and encourages the role of the patient as a partner in health care. Primary care is performed and managed by a personal physician often collaborating with other health professionals and utilizing consultation or referral as appropriate. iv. Types of clinicians (providers) involved in primary care 38. Primary care is provided by a health professional (clinician) who is specifically trained and skilled to provide comprehensive first contact and continuing care. This suitable provider should manage the “undifferentiated" patient with any undiagnosed signs, symptoms, or health concerns not limited by problem origin (biological, behavioural, or social), organ system, or diagnosis in these settings. The structure of the primary care practice may include a team of general practitioners and allied health professionals. Traditionally and as per practice, family physicians and paediatricians have formed the cornerstone of this service. However,

Page 13 of 109

providers of health care other than physicians may render some or most of the primary care services. Such providers may include nurse practitioners, clinical associates and some other mid-level health care providers.

39. The proposed primary health care services consist of the following components, interventions and services:

• Preventive services o Maternal, New-born, Children, Adults, Geriatrics • Diagnostic services o Radiology and Pathology Services • Treatment o Essential Drugs o Consultative services, Medical and Surgical procedure o Devices and Consumables • Rehabilitation services • Palliative services 40. The proposed primary health care team consist of the following health care providers: • Medical practitioner • Nurse practitioner • Psychologist and Social Worker • Physiotherapist and Occupational Therapist • Pharmacist • Dietitian • Dental practitioner, dental therapists and oral hygienists • Optometrist • Biokineticist • Podiatrist • Orthotist • Speech Therapist and Audiologist • Anaesthetist • Psychiatrist

8. Preventative Services

41. Disease prevention programs contribute to a better quality of life and increased life expectancy. Prevention is defined as 'approaches and activities aimed at reducing the likelihood that a disease or disorder will affect

Page 14 of 109

an individual; interrupting or slowing the progress of the disorder or reducing disability'. Preventative services for communicable and non-communicable diseases are proposed. The proposed preventive health care services include services for pregnancy, children, adults as well as geriatrics. The proposed services (table 2-3) consists of four types of services: • Immunizations and screening tests for the early detection of disease; • Counselling for health-related behaviour change; and • Preventative interventions.

Table 2. Preventative Services for Pregnancy Category of Interventions and Description Intervention/Service Codes Services and Services Interventions

Prevention of Pregnancy Female sterilisation 2492 Copper containing intra- G03AC08 uterine device G03AD01 LNG-IUS G02BA03 Progesterone-only G03AC06 Implants G03DA02 Progesterone -only pills G03AC01 Progesterone-only G03DC02 injectables G03AA07 Combined oral G03AB03 contraceptives G03AA09 Emergency pills G03AB05 G03AA10 G03AB06 0020 0027 Male sterilisation 2207 (Vasectomy) Termination of pregnancy 2448/2452 Pre-conception Screening (9) Health Education & Obesity counselling for BMI over Part of consultation Counselling 30 0015 Obesity screening Blood pressure screening

Rapid HIV test Screening for HIV using rapid 4614/0016/0017 test kits. Rubella test Immunity to rubella by previous 3946 exposure or vaccination

Page 15 of 109

Essential screening during pregnancy (9) Rapid HIV test Screening for HIV using rapid 4614 tests kits according to national guidelines. TB screening: TB screening for both HIV Questionnaire positive and negative women at each antenatal visit using a questionnaire Syphilis serology Two Rapid test for syphilis 3951 during pregnancy Rhesus (D) blood group Rhesus (D) blood group, using a 3765 rapid test Haemoglobin (Hb) level Haemoglobin (Hb) level, using a 3762 portable haemoglobinometer or copper sulphate screening method. Repeat Hb measurements at 28-32 weeks gestational age Urine dipstick test Urine dipstick testing for protein 4188/0014 and glucose at each antenatal visit. 2 X 2D Ultrasound scan Routine obstetric ultrasound 3615 preferable 1st one less than 12 weeks and second one less than 24 weeks gestational age. Targeted extra ultrasound for high risk individuals. Targeted ultrasound where clinically indicated ABO blood group Blood type screening 3764 Screening for down’s 4540, syndrome: 4546 4552 Blood glucose screening Screening for blood glucose 4057/4050 using fasting finger prick Hepatitis B screening Screening for Hepatitis B virus 3942 at first antenatal visit Screening for mental Screening for antenatal and Part of consultation health disorders postpartum mental health disorders. Interventions to be bundled with existing medical assessments done using appropriate screening tools. Total of four screening pre and postnatally. Depression, anxiety, substance abuse, psychosis1 Non-routine /Targeted screening tests Rubella serology: Screening for immunity against 3946 rubella

Page 16 of 109

Preventive interventions(9) Ferrous sulphate tablets Iron supplement to prevent B03AA07 200 mg daily anaemia in pregnant women B03AD03 Calcium tablets 1000 mg Calcium supplements to prevent See essential medicine list daily complications of pre-eclampsia Folic acid tablets five Folic acid supplement to prevent B03BB01 milligram daily neurodevelopmental disorders Tetanus toxoid (TT) To prevent neonatal tetanus J07AM01 immunisation First pregnancy: TT1 at first antenatal visit, TT2 four weeks later and TT3 six months later ○ later pregnancies: Two TT boosters, one in each pregnancy at the first visit, for the next two subsequent pregnancies, at least one year apart ○ a total of five properly spaced doses of TT provide life- long protection against tetanus Exercises(10)(11)(12)(13) All pregnant women 308; 313;501;505 509;708 901,903,909,912,908,923,926, 927,928,929,931,925,915,916, 917,920,921,920,930,933,934,936

Page 17 of 109

Table 3. Preventive services for children and adults

Category of Services Interventions and Description Service/Intervention and Interventions Services code

New-born preventative services Hypothyroidism screening Hypothyroidism 4507 screening in new-borns Hemoglobinopathies Screening for sickle cell 3770 or 3811 screening disease in new-borns PKU screening Screening for 4128 phenylketonuria in new- borns Syphilis test Screening for syphilis in 3951 new-borns Bilirubin test Screening for jaundice in 4009 new-borns New-born Hearing Screening for hearing Part of consultation screening(14) loss in new-born Vision Screening for children 3- Hearing 5 years as set out in the Speech and language Integrated School Health Physical (gross and fine Programme motor)(15)

Expanded Program on Immunisation Polio vaccine Vaccination according to J07BF03; J07AN01; Rotavirus vaccine national guidelines J07AG01; J07AG52; Diphtheria vaccine J07AL02; J07BC01; Tetanus vaccine J07BD01; J07BH01; Pertussis vaccine J07CA01; J07CA02; Haemophilus Influenza J07CA05; J07CA06; Type B J07CA09 Pneumococcal Conjugated 0022 Virus Measles/MMR BCG Hepatitis B vaccine

Screening and counselling for non-communicable diseases Health Education & Health education and Part of consultation Counselling counselling for adults Obesity screening and who are overweight or counselling obese: part of Blood pressure screening consultation Fasting Plasma Glucose Screening for diabetes in 4057/4050 adults who are 936,901,903,909,908,92 2

Page 18 of 109

overweight with risk factors (16)

Thyroid screening Annual screening in high 4507 risk individuals Vitamin D screening Annual screening for No evidence Vitamin D Dual energy x-ray Screening for 50120 absorptiometry (DXA) test osteoporosis in women and men who are at high risk

Random total cholesterol Men and women aged 35 4025 (fasting test) and older for lipid disorders. Men and women aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease.

Mammogram (+ ultrasound Mammogram once every 34100; 34101 if required e.g. dense 2 years for women ages breast tissue)(17)(18) 50 – 74 At risk individuals from 40 according to national guidelines Pap smear, Liquid based Screening for cervical 4566 cytology, HPV test(19) cancer. 4434 Pap smear every year in HIV positive women Pap smear every 3 years in women over 30 HPV test every 5 years in women above 30 as per guidelines. Faecal Occult Blood Test: Annually 4351 primary screening(20)(21)(22) Colonoscopy(20) Every 10 years 1653 or 1656; Sigmoidoscopy(20)(22) Every 5 years 1676 Low-dose computed Annual screening for lung tomography scan(23) cancer in adults ages 55 to 80 years with history and currently smoke or have quit within the past 15 years. Preventive interventions Aspirin Low-dose aspirin for high B01AC06 risk men for cardiovascular diseases Statin therapy(24)(25) For adults ages 40 – 75 C10AA years with no history of cardiovascular disease

Page 19 of 109

(CVD) who have one or more CVD risk factors and a calculated 10-year CVD event of 10% or greater.

Vitamin D supplement + Adults age 65+ who are A1CC Calcium(26)(27) at high risk for falls.

Exercise interventions Exercise interventions to 901,903,909,908,912,92 prevent falls in 3,926,929,931,925,922,9 community-dwelling 36,933,934 adults 65 years or older who are at increased risk for falls(28).

Cryotherapy/LEETZ/Colpo Prevention of Cervical scopy(19) Cancer in high risk Vaccination Varicella Vaccine Two doses for adults who J07BK01 have never received the J07BK02 vaccine J07BK03 Flu Vaccine For at-risk patients J07BB01 (immune compromised) J07BB02 once a year J07BB03 Hepatitis A Vaccine(29) Vaccine to high risk J07BC02 individuals (2 doses) Hepatitis B Vaccine (30) Vaccine for high risk J07BC01 individuals (3 doses) Measles, mumps, rubella 1 – 2 doses if no history J07BD52 (MMR) vaccine of the vaccination or disease. Can be given after age 40 if at high risk. Evidence Meningitis (meningococcal) 1 dose for ages 19 – 24 if J07AH07 Vaccine no history of vaccination. J07AH08 Can be given after age 40 if at high risk. Pneumonia 2 dose for those 65 and J07AL01 (Pneumococcal) older. Those at high risk J07AL02 Vaccine(31) or with a history of asthma or smoking should have 1 dose between ages 19 and 64 with a booster 5 years later. Shingles (herpes 2 doses (minimum 8 J07BK zoster)(32) weeks apart) for those 50 and older High risk Tetanus, diphtheria and 1 dose if no history of J07AJ whooping cough pertussis vaccine (pertussis) regardless of interval

Page 20 of 109

since last tetanus vaccine, followed by tetanus every 10 years. This vaccine is recommended especially if one has contact with children under age 1 Screening and counselling for communicable diseases TB screening Screening for TB in all Part of consultation patients seen in the facility at first point of contact with health care workers, except in emergency room using a questionnaire

TB patient household Assessment of Part of consultation assessment household members to identify at risk members for chemoprophylaxis Voluntary Counselling and Voluntary Counselling 614 Testing and Testing for HIV with a rapid test Hepatitis B screening Screening for hepatitis in 4531 adults at high risk Screening for chlamydia, Annual screening and 3951 syphilis, gonorrhoea using counselling for swap(33) chlamydia, gonorrhoea and syphilis for adults who are at high risk (17 - 24 age group) high of STI Check evidence for high risk. Screening for mental Screening for mental Part of consultation health disorders disorders using appropriate tools on an annual basis.

Screening for Neurocognitive disorders Part of consultation neurocognitive disorders screening for the elderly using appropriate tools on an annual basis Functional screening Screening for eye Eye screening conditions every 1-2 years Hearing screening Screening for hearing every 1-2 years Functional assessment Risk assessment to 901, 903, 909, 908, 923, Risk assessment for falls prevent risk of falling 927, 928, 913, 914, 915, 916, 917, 920, 922, 930, 933, 934, 936

Page 21 of 109

Preventative interventions Malaria Issuing of prophylaxis P01B chemoprophylaxis(34) prior to visiting malaria areas for high risk individuals Pre/post exposure Pre-exposure prophylaxis B01AC06 prophylaxis for HIV for high risk and post- exposure for exposed individuals Male circumcision Voluntary Male 2133; 2137; 2139 Circumcision

Page 22 of 109

9. Diagnostic services

42. Diagnostic services in the form of pathology tests and imaging support effective delivery of health care. Pathological services and Radiological services are proposed for diagnosis of acute and chronic conditions. 43. The proposed services are recommended for a specified clinical indication and not merely as a routine procedure. Furthermore, the diagnostic tests are to be provided in line with national policies which requires the setting, monitoring and enforcing of quality control standards to ensure patient safety. Requisition of these diagnostic procedures should therefore consider the following; • The investigations comply with national and/or provincial policies (where applicable) and current best evidence in making clinical decisions about the care of patients, i.e. clinically justifiable • Whether the previous patient results still have clinical relevance • Whether the investigation is required to ensure patient safety • If the investigation is required for quality assurance purposes

9.1 Pathology Services 44. The proposed pathology services include the following fields; • Chemical pathology • Haematology • Microbiology and Virology • Serology

Table 4: Point of Care Services Category PMB Service Description Codes Haematology Bleeding time 3713 Haemoglobin estimation 3762 Parasites in blood smear 3865 D-Dimer 3856 INR 3805 Serology Hepatitis Rapid Viral Ab 3942 HIV Ab - Rapid Test 4614 Syphilis rapid test 3951 Chemical pathology Bilirubin - Reflectance 4008 Chol/HDL/LDL/Trig (Specific 4025 Indications - See BHF Benefit Guide) Cholesterol total 4027

Page 23 of 109

Glucose strip-test with 4050 photometric reading Urine dipstick, per stick 4188 (irrespective of the number of tests on stick) HCG: Latex agglutination: 4448 Qualitative (side room) HCG: Monoclonal 4450 immunological: Qualitative Troponin isoforms: Each 4161 HbA1C 4064 Identification of drug: qualitative 4287 Potassium 4113 Uric acid 4155 AST 4130 Urea breath test 4378 Urea, Creatinine 4151, 4032 Micro Albumin: Qualitative 4262 Foam test: Amniotic fluid 4390 Lactate levels 4086 C-reactive protein (CRP) 3947 BNP 4488 NT-proBNP U&E 4171 Microbiology and virology Cryptococcal Screening POCT

Table 5: Pathology services Category PMB Service Description Codes Haematology Antiglobulin Test (Direct 3709 Coombs) Blood group abo 3764 Blood Group Rh Antigen 3765 CD4 count 3816 Coombs- Indirect 3709 D-Dimer 3856 Differential count 3783 Erythrocyte Sedimentation Rate 3743 (ESR) FBC (Excl. ESR) 3755 Haemoglobin and MCV 3762; 3916 Haemoglobin Estimation 3762 Haptoglobin 3772 INR 3805 INR dosage Malaria Ag 3792

Page 24 of 109

Malaria Thick Smear 3883 Malaria Thin Smear for 3865 Confirmation Packed Cell Volume: 3791 Haematocrit Platelet 3797 PTT 3837 Red Cell Antibody screen (Coomb’s test or the “Direct Antiglobulin Test (DAT) Reticulocyte Count 3809 Rhesus Factor (Rh) WCC Diff 3783 White Blood Cell Count 3785

Chemical Pathology 17-Oh Progesterone 4520 ACTH 4523 AFP 4522 Albumin 3999 ALK. Phosphatase 4001 ALT (SGPT) 4131 Amylase 4006 Arterial blood gas 4076 AST (SGOT) 4130 Beta HCG (Qualitative) 4450 Beta HCG (Quantitative) 4451 BHCG (Male Tumour Marker) 4451 Bilirubin Conj. 4010 Bilirubin Total 4009 BRCA test C Reactive Protein 3947 Ca 125 4462 Ca 15-3 4468 Ca 19-9 4460 Calcium (Albumin Corrected) 4017; 3999 Calcium (serum) 4016 CEA 4471 Cholesterol 4027 Cortisol- Serum 4499 Creatine Kinase (Ck) 4132 Creatinine /GFR 4032 DHEAS 4500 Estradiol 4503 Ferritin 4528 Folate-Serum ONLY, not RBC 4533 Free T4 4482 FSH 4516 Gamma-Glutamyl Transferase 4134 (GGT) Glucose 4057 Glucose Tolerance Test 4049

Page 25 of 109

HbA1c 4064 Identification of Drug: Qualitative 4287 Lactate Dehydrogenase-LDH 4133 LDH 4133 LDL 4027 LDL-Cholesterol (LDL-C) 4026 Lipase 4085 Luteinizing Hormone (LH) 4517 Magnesium 4094 Osmolality 4093 Parathyroid Hormone 4512 PCT Procalcitonin 4538/4539 Phenytoin Phosphate 4109 Plasma or whole blood lactate 4086 Pleural effusion Protein Potassium (serum) 4113 Progesterone 4521 Prolactin (screening and 4537 monitoring pituitary tumour) Protein electrophoresis 4105 PSA 4519 S100b 4469 Serum Iron 4071 SHBG 4526 Sodium 4114 Testosterone- Total 4501 Therapeutic Drug Level: Dosage 3806 Total Protein 4117 Transferrin 4144 Triglycerides 4147 Troponin T/I High sensitivity 4161 TSH 4507 U&E 4171 Uric Acid (serum) 4155 Urine Dipstick, Per Stick 4188 (Irrespective of The Number of Tests on Stick) Urine albumin: creatinine ratio Urine Microalbumin 4261 Urine Protein: creatinine ratio Vitamin B12 4491 Vitamin D 4492 Serology Anti-Double Stranded DNA 3948 Antibodies Antinuclear Antibodies 3934 ASO Titre 3943; 3944; 3948 Bilharzia Igg Elisa (Soluble Egg) 3948 Bilharzia IGM Elisa (Adult 3946 Worm) Brucella Igg, IGM 3948; 3946

Page 26 of 109

Cyclic Citrullinated Peptide- 4600 CCP Syphilis Serology 3951; 3949 Cytomegalovirus, IgG, IgM 3948, 3946 Fecal Calprotectin test Hepatitis A IgM and IgG 4531 Hepatitis B core antibody IgM 4531 (HBcIgM) Hepatitis B e-antibody (HbeAb) 4531 Hepatitis B e-antigen (HBeAg) 4531 Hepatitis B surface antibody 4531 (HBsAb) Hepatitis C antibody 4531 Hepatitis: Per Antigen or 4531 Antibody HIV I&II ELISA (discordant 3932; 4615 rapids) HIV PCR for infants 4434 HIV Rapid Test 4614 HSV IgM and IgG 3946; 3948 Measles IgG And IgM 3948; 3946 Mumps IgG and IgG 3948; 3946 Paediatric Food Screen Plus 4508 Breakdown Parvovirus B19 IgM and IgG 3948; 3946 Phadiotop Inhalant Allergy 4506 Screen Plus Breakdown Rheumatoid Factor 4182 Rickettsia Igg, IGM 3948; 3946 RPR on serum 3951; 3949 Rubella IgG Avidity 3948 Rubella IgM, IgG 3946; 3948 Skin Prick Allergy Test, 220 T Pallidum Elisa IGG 3948 T Pallidum Elisa IGM 3946 Total IGA 4182 Total Igg 4182 Total IGM 4182 Toxoplasmosis 3946/3948 Triglycerides 4147 Troponin T/I 4161 TSH 4507 VZV IgM and IgG Microbiology & Virology Bacterial Culture Testing- Swab, 3879,3893,3895,3909,46 Stool, CSF, Urine, Pus, Fluid, 51,3923,3924,3926,4652 Tissue, Other Bacterial Microscopy, - Swab, 3867,3869,3878,3883 CSF, Stool, Urine, Pus, Fluid, Tissue, Other

Page 27 of 109

Bacterial Sensitivity Testing- 3887,4650,4653 Swab, CSF, Stool, Urine, Pus, Fluid, Tissue, Other Bilharzia CCA (Urine) 3946 Bilharzia Microscopy 3948 Clostridium difficile 3889 Toxin test Cryptococcal Antigen 3939 CSF Cell Count & Chemistry 4407 Fungal Culture Testing- Swab, 3901,4652 Stool, CSF, Urine, Pus, Fluid, Tissue, Other Fungal Microscopy, - Swab, 3868 CSF, Stool, Urine, Pus, Fluid, Tissue, Other Fungal Sensitivity Testing- 4650,4653 Swab, CSF, Stool, Urine, Pus, Fluid, Tissue, Other HIV Drug Resistance Test 4766 (Genotypic) HIV Viral Load 4429 MCS (Microscopy, culture band 3867 sensitivity) Pleural effusion MCS 3867 RVPCR 4433 Enterovirus PCR 3974 HSV PCR 5569 Sputum Microscopy Tb 3885/3881/3867 Stool parasites – Bilharzia & 3980 other parasites

TB Culture 4651; 3915; 3918; 3919 TB Drug Susceptibility 4652; 4653; 4654; 4650 TB Line Probe Assay (Hain 3930; MTBDR) Tb PCR 3974 OR 4434 Tb Sensitivity Single Mic 4655 Tb Sensitivity Test – Phenotypic 3930/3974/4434; 3920 or Genotypic TB Smear microscopy 3919; 3915 Urine Tb Lam 3882 X-pert MTB/RIF No codes Cytopathology Cytology for aspirates including lymph nodes Pap smear 4566

Page 28 of 109

9.2 Radiological Services 45. The proposed imaging services include: • X-ray • Ultrasound • CT Scan

Table 6: Radiology Services Category Radiology Interventions and Radiography PMB Intervention Codes Services Codes X-Ray Head 14100 Mandible x-ray 045 Mandible 14120 Maxillofacial cephalometry x- 69 Maxillo-facial cephalometry ray 11120 Nasal bones x-ray 47 Nasal bone 13130 Naso-pharyngeal soft tissue 20100 Neck soft tissue x-ray 67 Postnasal studies: Lateral neck 12120 Orbits x-ray for foreign body 63 Facial bones and/or orbits 12100 Orbits x-ray less than three 43 Facial bones and/or orbits views 12110 Orbits x-ray three or more 43 Facial bones and/or orbits views including foramina 13100 Sinuses single view 41 Paranasal sinuses 13110 Sinuses two or more views 041 Paranasal sinuses 10100 Skull x-ray 39 Skull studies

Neck 20100 X-ray of soft tissue of the 067 Post-nasal studies: Lateral neck neck 51120 Cervical spine, more than 2 017 Cervical - myelography views x-ray 51110 Cervical spine, one or two 017 Spine X-ray per regional view views x-ray 51130 Cervical spine, more than two 017 Spine, per region views with stress 51100 Cervical spine, stress views 012 Stress studies only Chest 30100 Chest single view x-ray 107 Chest 30110 Chest two views, Pa and Lateral x-ray 34100 Mammography 175 Mammography: Unilateral or 34101 Mammography unilateral bilateral

30180 Sternum 113 Sternum or sterno-clavicular joints

Abdomen and 40110 Abdomen multiple views 125 Control films of the abdomen (not Pelvis including chest x-rays being part of examination for barium meal, barium enema, pyelogram, cholecystogram, cholangiogram, etc.)

Page 29 of 109

40105 Abdomen supine and 127 Acute abdomen or equivalent erect/decubitus x-rays studies 40100 Abdomen x-ray 125 Abdomen (including base of chest and/or pelvis) 43110 Pelvimetry multiple views x- 147 Pelvimetry ray 43100 Pelvimetry single x-ray 147 Pelvimetry 56120 Hips and pelvis x-ray 27 Pelvis (sacro-iliac or hip joints only to be added where an extra set of views is required) 53110 Lumbar spine, one or two 017 Per region, e.g. cervical, sacral, views x-ray coccygeal, one region thoracic - Spinal column 56120 Pelvis and hips x-ray 27 Pelvis (sacro-iliac or hip joints only to be added where an extra set of views is required) 55100 Pelvis x-ray 27 Pelvis (sacro-iliac or hip joints only to be added where an extra set of views is required) 52100 Thoracic spine one or two 017 Per region, e.g. cervical, sacral, views x-ray coccygeal, one region thoracic - Spinal column

61128 Acromio-clavicular joint plus 113 and 021 Sternum or sterno-clavicular joints, stress study Stress studies 61100 Clavicle left x-ray 003 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should be added, e.g. wrist or hand) 61105 Clavicle right x-ray 003 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand)

63100 Elbow left 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 65105 Elbow right x-ray 003 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 65120 Finger x-ray 1 Finger, toe 64100 Forearm left x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 64105 Forearm right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or

Page 30 of 109

ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 65100 Hand left x-ray 003 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 65105 Hand right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 62100 Humerus left x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 62105 Humerus right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 65140 Scaphoid left x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 65145 Scaphoid right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 61110 Scapula left x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 61115 Scapula right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 61140 Shoulder left + subacromial 003 Limb per region, e.g. shoulder, impingement views x-ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 61130 Shoulder left x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or

Page 31 of 109

ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 61145 Shoulder right + subacromial 3 Limb per region, e.g. shoulder, impingement views x-ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 61135 Shoulder right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 65130 Wrist left x-ray 003 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand)

65135 Wrist right x-ray 3

Lower Limbs 74100 Ankle left x-ray 003 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 74105 Ankle right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 74110 Ankle left, with stress 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 74115 Ankle right, with stress 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 72120 Knee left including patella x- 003 Limb per region, e.g. shoulder, ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 72110 Knee left with more than two 3 Limb per region, e.g. shoulder, views x-ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of

Page 32 of 109

views should not be added, e.g. wrist or hand) 72100 Knee left, one or two views x- 3 Limb per region, e.g. shoulder, ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 72125 Knee right including patella x- 3 Limb per region, e.g. shoulder, ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 72115 Knee right, more than two 3 Limb per region, e.g. shoulder, views x-ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 72105 Knee right one or two views 3 Limb per region, e.g. shoulder, x-ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 72150 Knee right and left standing 003 Limb per region, e.g. shoulder, views single view x-ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 73100 Lower leg left x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 73105 Lower leg right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 70120 Lower limbs full length study 009 Length studies per right and left pair x-ray of long bones 72140 Patella left x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 72145 Patella right x-ray 003 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 74150 Sesamoid bones one or both 3 Limb per region, e.g. shoulder, sides x-ray elbow, knee, foot, hand, wrist or

Page 33 of 109

ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 74145 Toe 001 Finger, toe 74140 Feet standing single view x- 3 Limb per region, e.g. shoulder, ray elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 71100 Femur left 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 71105 Femur right 003 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 74120 Foot left x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) 74125 Foot right x-ray 3 Limb per region, e.g. shoulder, elbow, knee, foot, hand, wrist or ankle (an adjacent part which does not require an additional set of views should not be added, e.g. wrist or hand) Ultrasound 230 US guidance 20200 Thyroid 5103 20210 Soft tissue of neck 5103 Soft tissue any region 30200 US Chest Wall, any region 30210 US Pleural space 5101 40200 US Abdominal wall 5103 41200 US upper abdomen 40210 US Whole abdomen including 3627 pelvis 42200 US Renal tract including 3628 bladder 43200 US Pelvis, trans-abdominal 3618 43205 US Female pelvis, trans- 5100 vaginal 43210 US Prostate, trans-rectal 5100 43220 US Testes 5103 43250 US Pregnant uterus, first 3615/5106 trimester 43260 US Pregnant uterus, second 3617 trimester

Page 34 of 109

43270 US Pregnant uterus, third 5107 trimester 34200 Ultrasound study of the 5103 breast 60200 US upper limb - soft tissue - 5103 any region 70200 US lower limb - soft tissue - 5103 any region 60230 US peripheral venous system 5113 upper limbs including pulse and colour doppler for deep vein thrombosis 70230 US peripheral venous system 5113 lower limbs including pulse and colour doppler for deep vein thrombosis 13300 CT of paranasal sinuses /Limited CT of sinuses 10300 CT Brain

10. Treatment and management of acute and chronic conditions

46. Treatment is defined as the application of medicines; surgery; and therapy to cure or mitigate disease, condition or injury. A list of essential medicines and procedures (medical and surgical) are proposed for the treatment of acute and chronic conditions. The standard treatment guidelines (STGs) provide guidance on management of certain conditions and the use of medicines by service providers. According to the STGs, medicines should be prescribed only when they are necessary for treatment following clear diagnosis as not all patients or conditions need prescriptions for medication. Furthermore, in certain conditions simple advice and general and supportive measures may be more suitable(35).

10.1 Essential Medicine List 47. For the medicines, a standard list of essential medicines is selected from the essential medicine list (EML) of the National Department of Health. The list consists of the PHC EDL and hospital EDL for both adults and children. The adoption of the EDL is proposed based on the scientific rigour through which the list is compiled. The medicines are selected based on disease prevalence, evidence on efficacy and safety, and comparative cost. Table 7 is an outline of the essential medicine list classified according to the therapeutic classes.

Page 35 of 109

Table 7: Essential Medicine List2 Therapeutic Class ATC INN EDL EDL LEVEL Codes ACE Inhibitors Benazepril C09AA01 Captopril Yes Paeds

C09AA02 Enalapril Yes All EDL

Alpha-blockers C02CA01 Prazosin Yes Paeds EDL Aminoglycoside J01GB06 Amikacin Yes Hosp and Paeds antibacterial EDL3 J01GB03 Gentamicin Yes Hosp and Paeds S01AA11 EDL S02AA14 S03AA06 A07AA08 Kanamycin Yes Hospital EDL J01GB04 S01AA24 Anaesthetic drugs N01AB01 Halothane Yes Hosp and Paeds EDL N01AX03 Ketamine Yes Hosp and Paeds EDL N01BB52 Lignocaine with adrenaline Yes All EDL N01BB02 Lignocaine without adrenaline Yes All EDL N01AX13 Nitrous oxide Yes All EDL N01AX10 Propofol Yes All EDL N01AB06 Isoflurane Yes Hosp and Paeds EDL N01AB08 Sevoflurane Yes Hosp and Paeds EDL N01BA03 Tetracaine Yes PHC and Hosp EDL N01AF03 Thiopental Yes Hosp and Paeds N05CA19 EDL Analgesic Non-opioids N02BE01 Paracetamol Yes All EDL Analgesic Opioids N01AH02 Alfentanil Yes Hosp EDL N02AB03 Fentanyl Yes Hosp and Paeds EDL N07BC02 Methadone Yes Hosp EDL

N02AA01 Morphine Yes All EDL

N02AB02 Pethidine Yes Hosp EDL N02AX01 Tilidine Yes Hosp and Paeds EDL N02AX02 Tramadol Yes PHC and Hosp EDL Angiotensin II Receptor Irbesartan Blockers C09CA01 Losartan Yes Hosp EDL

2 EML for outpatient use updated and published by the NDoH. 3 Hosp: Hospital, Paeds: Paediatrics

Page 36 of 109

Antacids A02AB01 Aluminium hydroxide Yes Hosp EDL A02AC01 Calcium carbonate Yes All EDL

Anti-acne P03AX01 Benzyl benzoate Yes PHC EDL

D10AE01 Benzyl peroxide Yes PHC and Hosp

EDL

D10AD01 Tretinoin Yes PHC and Paeds

EDL Anti-arrhythmic C01BD01 Amiodarone Hosp and Paeds EDL C01BB01 Lidocaine Yes All EDL C01BA01 Quinidine Yes Hosp EDL

Anti-diarrhoeal A07AA08 Kanamycin sulphate (Kantrexil) Yes PHC and Hosp EDL A07DA03 Loperamide Yes All EDL

A07CA Oral rehydration solution Yes All EDL Anti-emetics A03FA01 Metoclopramide Yes All EDL

A04AA01 Ondansetron Yes Hosp and Paeds

EDL

A04AA02 Granisetron Yes Hosp EDL

D04AA10 Promethazine Yes All EDL R06AD02 Anti-epileptic N03AF01 Carbamazepine Yes All EDL N03AA02 Phenobarbital Yes PHC and Paeds EDL N03AB02 Phenytoin Yes All EDL

N03AX11 Topiramate Yes Paeds EDL

N03AG01 Valproate Yes All EDL Vigabatrin N03AX09 Lamotrigine Yes All EDL Antifibrinolytics B02AA02 Tranexamic acid Yes Hosp and Paeds EDL Antifungals A07AA07 Amphotericin B Yes All EDL G01AA03 J02AA01 A01AB18 Clotrimazole Yes All EDL D01AC01 G01AF02 J02AC01 Fluconazole Yes All EDL

D01AC02 Miconazole Yes Paeds EDL

A07AA02 Nystatin Yes All EDL D01AA01 G01AA01 Antigout preparations M04AA01 Allopurinol Yes PHC and Hosp EDL

Page 37 of 109

M04AC01 Colchicine Yes Hosp EDL Anti-helminths P02CA03 Albendazole Yes All EDL P02CA01 Mebendazole Yes PHC and Paeds EDL Anti-histamines R06AE07 Cetirizine Yes All EDL R06AB04 Chlorphenamine Yes All EDL

R06AD02 Promethazine Yes All EDL

Antihypertensive anti- adrenergic C02AB Methyldopa Yes PHC and Hosp EDL Antihypertensive Clonidine imidazole receptor agonists Anti-inflammatory and antirheumatic products, Non-Steroids [NSAIDs] D11AX18 Diclofenac Yes Hosp EDL M01AB05 M02AA15 S01BC03 C01EB16 Ibuprofen Yes All EDL G02CC01 M01AE01 M02AA13 R02AX02 M01AB01 Indomethacin Yes Hosp EDL S01BC01 Anti-malarial agents P01BF01 Artemether / lumefantrine Yes All EDL P01BE02 P01BE03 Artesunate Yes All EDL P01AX06 Atovaquone / Proguanil P01BB01 P01BB51 P01BA01 Chloroquine Yes Hosp and Paeds EDL J01AA02 Doxycycline Yes All EDL

P01BA03 Primaquine Yes Hosp and Paeds EDL P01BD01 Pyrimethamine/Sufadoxine P01BD51 P01BC01 Quinine Yes All EDL Antimuscarinic agents A03BA01 Atropine Yes All EDL A03AB02 Glycopyrrolate Yes Hosp and Paeds R03BB06 EDL R01AX03 Ipratropium bromide Yes All EDL R03BB01

Anti-Parkinsons N04BA01 Levodopa/Carbidopa Yes Hosp EDL Biperiden Yes All EDL

N04BC05 Pramipexole Yes Hosp EDL

N04BC04 Ropinirole Yes Hosp EDL

Page 38 of 109

N04BC01 Bromocriptine Yes Hosp EDL

Antiprogestogens G03XB01 Mifepristone Yes PHC and Hosp EDL Anti-protozoals P02BA01 Praziquantel Yes All EDL

Anti-pruritics D02AB Calamine lotion Yes PHC and Paeds EDL D01AE13 Selenium sulphide Yes PHC and Hosp EDL R06AB04 Chlorphenamine Yes All EDL Anti-psoriatics D05AA Coal tar Yes All EDL D02AF Salicylic acid Yes PHC and Paeds

EDL Anti-psychotics (Atypical) N05AX08 Risperidone Yes All EDL

N05AH03 Olanzapine Yes Hosp EDL

Anti-psychotics (Typical) N05AD01 Haloperidol Yes All EDL N05AB02 Fluphenazine Yes PHC and Hosp EDL N05AF05 Zuclopenthixol decanoate Yes PHC and Hosp EDL N05AF05 Fluclopenthixol decanoate Yes PHC and Hosp EDL N05AG02 Pimozide N05AA01 Chlorpromazine Yes PHC and Hosp EDL Antiretrovirals J05AF06 Abacavir Yes All EDL J05AR23 Atazanavir/Ritonavir Yes PHC and Hosp EDL J05AE10 Darunavir/ritonavir Yes PHC EDL J05AE03 J05AF02 Didanosine Yes PHC EDL

J05AX12 Dolutegravir Yes PHC EDL

J05AG03 Efavirenz Yes All EDL J05AF09 Emtricitabine Yes All EDL J05AG04 Etravirine Yes PHC EDL

J05AF05 Lamivudine Yes All EDL

J05AR10 Lopinavir/ Ritonavir Yes All EDL J05AG01 Nevirapine Yes All EDL J05AX08 Raltegravir Yes PHC EDL J05AF04 Stavudine Yes PHC and Paeds EDL J05AF07 Tenofovir Yes All EDL J05AF13 J05AF01 Zidovudine Yes All EDL Antiseptics and A01AB03 Chlorhexidine aqueous solution Yes All EDL disinfectants

Page 39 of 109

A01AB03 Chlorhexidine mouthwash Yes All EDL D06AX01 Fusidic acid D09AA02

D08AC52 Chlorhexidine in 70% alcohol Yes All EDL D08AC02 D08AG03 Tincture of iodine BP Yes PHC EDL

D08AG02 Povidone iodine Yes All EDL

D08AX08 Ethanol Yes Hosp EDL D06BA01 Silver sulfadiazine Yes Hosp and Paeds EDL D02AB Zinc oxide Yes PHC and Paeds EDL

Antithrombotic agents B01AA03 Warfarin Yes Hosp and Paeds (including anticoagulants) EDL B01AB01 Heparin Yes Hosp EDL

B01AB05 Enoxaparin Yes Hosp and Paeds EDL B01AD01 Streptokinase Yes PHC and Hosp EDL Anti-Tuberculosis agents J04AB02 Rifampicin Yes All EDL J04AC01 Isoniazid Yes All EDL

J04AK01 Pyrazinamide Yes All EDL

J04AK02 Ethambutol Yes All EDL J04AD03 Ethionamide Yes All EDL Antivirals (active against J05AB01 Acyclovir Yes All EDL varicella zoster) J05AB06 Ganciclovir Yes Hosp EDL

J05AB14 Valganciclovir Yes Hosp and Paeds

EDL

N03AE01 Clonazepam Yes Hosp and Paeds EDL Diazepam Diazepam Yes All EDL N05BA06 Lorazepam Yes Hosp and Paeds EDL N05CD08 Midazolam Yes All EDL N05BA04 Oxazepam Yes Hosp EDL Beta blockers (selective) C07AB03 Atenolol Yes All EDL

C07AG02 Carvedilol Yes PHC and Hosp

EDL

C07AA05 Propranolol Yes Hosp and Paeds

EDL

C07AG01 Labetalol Yes Hosp and Paeds EDL Beta2 agonists R03AC02 Salbutamol Yes All EDL R03AC04 Fenoterol Yes Hosp EDL

Terbutaline

R03AC13 Formoterol Yes All EDL

Page 40 of 109

R03AC12 Salmeterol Yes All EDL Beta-lactam antibacterials J01CA04 Amoxicillin Yes All EDL (natural penicillins, penicillin with extended spectrum and Beta- J01CR02 Amoxicillin/Clavulanic Acid Yes All EDL lactamase resistant J01CA01 Ampicillin Yes All EDL penicillins) J01CE08 Benzathine benzylpenicillin Yes All EDL

J01CE09 Procaine Benzyl penicillin Yes Hosp and Paeds EDL J01CE01 Benzyl penicillin (Pen G) Yes Hosp and Paeds EDL J01CF02 Cloxacillin Yes Hosp and Paeds EDL J01CF05 Flucloxacillin Yes All EDL J01CE02 Phenoxymethyl penicillin (Pen Yes All EDL VK) Biguanides Metformin Yes PHC and Hosp EDL Bile acid sequestrants Cholestyramine Yes Paeds EDL Blood products Cryoprecipitate Yes Hosp and Paeds EDL Packed red cells Yes Hosp and Paeds EDL Platelets Yes Hosp and Paeds EDL Fresh frozen plasma Yes Hosp and Paeds EDL Calcium channel blockers C08CA01 Amlodipine Yes All EDL C08CA05 Nifedipine Yes PHC and Hosp EDL Carbapenem antibaterials J01DH51 Imipenem/Cilastin Yes Hosp EDL J01DH02 Meropenem Yes Hosp EDL

Cardiac glycosides C01AA05 Digoxin Yes PHC and Hosp EDL Coagulation factors B02BD02 Factor VIII Yes Hosp and Paeds (antihaemophilia agents) EDL B02BD04 Factor IX Yes Hosp and Paeds EDL Factor XIII Contraceptives G03AC08 Etonogestrel Yes PHC EDL G03AD01 Levonorgestrel Yes PHC and Hosp EDL G02BA03 Levonorgestrel IUD

G03AC06 Medroxyprogesterone Yes PHC and Hosp

G03DA02 EDL

G03AC01 Norethisterone Yes PHC and Hosp

G03DC02 EDL

G03AA10 Gestodene and ethinylestradiol Yes PHC EDL G03AB06

Page 41 of 109

G03FA01 Estradiol/norethisterone acetate Yes PHC and Hosp EDL G02BA03 Plastic IUD with progestogens Yes PHC and Hosp EDL G02BA02 Copper T Contrast media V08BA02 Barium Sulphate Yes Hosp EDL V08AB02 Iohexol Hosp EDL V08AB05 Iopromide Hosp EDL

Corticosteroids for systemic use H02AB01 Betamethasone Yes All EDL

H02AB09 Hydrocortisone Yes All EDL

H02AB02 Dexamethasone Yes Hosp and Paeds EDL H02AB04 Methylprednisolone Yes Hosp and Paeds EDL H02AB07 Prednisone Yes All EDL H02AB06 Prednisolone Yes All EDL Corticosteroids for topical D07AA02 Hydrocortisone Yes All EDL use D07XA01 D07AC01 Betamethasone Yes All EDL D07XC01 D07AB19 Dexamethasone Yes Hosp and Paeds D07XB05 EDL D10AA03 R01AD03 D07AA01 Methylprednisolone Yes Hosp and Paeds D10AA02 EDL Disease Modifying agents L01BA01 Methotrexate Yes Hosp and Paeds EDL A07EC01 Sulphasalazine Yes Hosp EDL L04AX01 Azathioprine Yes Hosp and Paeds EDL Leflunomide L01AA01 Cyclophosphamide Yes Hosp and Paeds EDL Diuretics C03DA01 Spironolactone Yes All EDL S01EC01 Acetazolamide Yes All EDL

C03CA01 Furosemide Yes All EDL

C03AA03 Hydrochlorothiazide Yes All EDL

Ectoparasiticides P03AC04 Permethrin Yes PHC EDL

Emergency drugs A07BA01 Activated charcoal Yes All EDL C01CA24 Adrenaline Yes All EDL

A03BA01 Atropine Yes All EDL

A03AB02 Glycopyrrolate (glycopyrronium Yes Hosp and Paeds bromide) EDL V03AN01 Oxygen Yes All EDL

Page 42 of 109

V07AB Water for injection Yes Hosp and Paeds EDL V03AE01 Polystyrene sulphonate Yes Hosp EDL R05CB01 Acetylcysteine Yes Hosp and Paeds EDL V03AC01 Deferoxamine Yes All EDL

A12AA03 Calcium gluconate Yes All EDL D11AX03 V03AB15 Naloxone Yes All EDL J06AA03 Polyvalent snake antivenom Yes Both Hosp J06 Spider antivenom Yes Both Hosp J06 Scorpion antivenom Yes Both Hosp J06 Boomslang antivenom Yes Adult Hosp N07AA02 Pyridostigmine Yes Both Hosp B05BA03 Dextrose 50 % Yes All EDL B05XA02 Sodium bicarbonate Yes Both Hosp B05XA01 Potassium chloride Yes All EDL A12CC02 Magnesium sulphate Yes All EDL B05XA05 Emollient and protectants D02AX Aqueous cream Yes PHC and Paeds EDL D02A Emulsifying ointment Yes All EDL D02AC Petroleum Jelly Yes PHC EDL

D02AB Zinc oxide cream Yes PHC EDL

D02AB Zinc and castor oil Yes PHC and Paeds EDL D02BA Sunscreen >SPF 50 Yes Paeds EDL P03BX01 Diethyltoluamide ointment Yes Paeds EDL Enzymes A09AA02 Lipase Yes Hosp and Paeds EDL A09AA02 Amylase Yes Paeds EDL A09AA02 Protease Yes Paeds EDL Ethers chemically close to N04AB02 Orphenadrine Yes PHC and Hosp antihistamines EDL Floroquinolone J01MA02 Ciprofloxacin Yes All EDL antibaterials S01AE03 S03AA07 J01MA12 Levofloxacin Yes Hosp and Paeds S01AE05 EDL J01MA14 Moxifloxacin Yes All EDL S01AE07 J01MA01 Ofloxacin Yes Hosp and Paeds S01AE01 EDL S02AA16 Glycopeptide antibacterials A07AA09 Vancomycin Yes Hosp and Paeds

J01XA01 EDL H2 antagonists

Page 43 of 109

A02BA02 Ranitidine Yes Paeds EDL HMG CoA reductase C10AA05 Atorvastatin Yes PHC and Hosp inhibitor EDL C10AA01 Simvastatin Yes All EDL

Hormonal preparations Oxytocin Yes PHC and Hosp EDL H01BB02 Oxytocin/ergometrine Yes PHC

G02AC01 Ergometrine Yes PHC and Hosp EDL H01BA02 Desmopressin Yes PHC and Hosp EDL H03AA01 Levothyroxine Yes All EDL G03BA03 Testosterone Yes Hosp EDL

G03GB02 Clomifene Yes Hosp EDL

Imidazoles A01AB18 Yes All EDL D01AC01 G01AF02 D01AC08 Ketoconazole Yes Hosp EDL G01AF11 J02AB02 Immune globulins J06BB01 Anti-D immunoglobulin Yes All EDL J06BB04 Hepatitis B immunoglobulin Yes All EDL J06BA01 Human normal immunoglobulin Yes Paeds EDL J06BA02 J06BB16 Palivizumab (Immunoglobin g) J06BB05 Rabies immunoglobulin Yes All EDL J06BB02 Tetanus immunoglobulin Yes Hosp and Paeds EDL J06BB03 Varicella Zoster Yes Hosp and Paeds immunoglobulin EDL Inhaled corticosteroids R03BA02 Budesonide Yes All EDL R03BA01 Beclomethasone Yes Hosp and Paeds EDL R03BA05 Fluticasone Yes All EDL

Inotropes C01CA24 Adrenaline Yes All EDL C01CA04 Dopamine Yes Hosp and Paeds EDL C01CA06 Phenylephrine Yes Hosp EDL

C01CA07 Dobutamine Yes Hosp and Paeds EDL Insulin A10AD Biphasic Yes All EDL A10AB Fast-acting Yes All EDL

A10AC Intermediate to long-acting Yes All EDL

Page 44 of 109

Insulin Analogue A10AD04 Biphasic insulin analogue Intravenous solutions B05BA03 Dextrose 5% Yes All EDL B05BA03 Dextrose 10 % Yes All EDL B05BA03 Dextrose 15 % Yes Hosp and Paeds EDL B05BA03 Dextrose 50 % Yes All EDL

B05XA03 Sodium Chloride 0.45 % Yes Hosp and Paeds

EDL

B05XA03 Sodium Chloride 0.9 % Yes All EDL

B05XA03 Sodium Chloride 5% Yes Adult Hosp B05BB01 Ringers lactate Yes Adult Hosp B05BB02 Half strength Darrow’s solution Yes Paeds with 5% dextrose B05BA10 Neonalyte Yes Paeds B05BB02 Maintelyte B05BC01 Mannitol Yes Hosp and Paeds EDL B05AA07 Tetrastarch B05AA01 Albumin 20% Yes Both Hosp Iron Preparations B03AA03 Ferrous gluconate Yes PHC and Paeds EDL B03AA07 Ferrous sulphate Yes All EDL B03AD03 B03AC Ferrous lactate Yes PHC and Paeds EDL B03AA02 Ferrous fumarate Yes PHC EDL V03AC01 Desferroxamine Yes All EDL (Deferoxamine) B03AC Iron dextran Keratolytic agents D06BB04 Podophyllin Yes Hosp and Paeds EDL Laxatives A06AB56 Sennosides A and B Yes PHC and Hosp EDL A06AD11 Lactulose Yes All EDL A06AB02 Bisacodyl

A06AA01 Liquid paraffin Yes Paeds EDL

A06AD17 Sodium phosphate and Sodium Yes Hosp and Paeds A06AG01 bisphosphate EDL

A06AD15 Polyethylene glycol Yes Hosp and Paeds EDL A06AC01 Ispaghula Yes Paeds EDL A06AC51 Lincosamide antibacterials J01FF01 Clindamycin Yes Hosp and Paeds EDL Mast cell stabilisers R01AC01 Sodium chromoglycate Yes PHC and Hosp R03BC01 EDL Muscle relaxants

Page 45 of 109

M03CA01 Dantrolene sodium Yes Hosp and Paeds EDL M03AB01 Suxamethonium chloride Yes Hosp and Paeds EDL M03AC09 Rocuronium bromide Yes Hosp and Paeds EDL M03AC09 Vecuronium bromide Yes Hosp EDL Nasal preparations R01AA05 Oxymetazoline Yes All EDL R01AB07 R01AX10 Normal saline nasal drops Yes PHC EDL R01AD12 Fluticasone furoate Yes PHC EDL

R01AD05 Budesonide Yes PHC and Hosp EDL Neuromuscular block N07AA01 Neostigmine Yes Hosp and Paeds reversal agents EDL

Nitrates C01DA02 Glyceryl trinitrate Yes Hosp EDL

C01DA08 Isorbide dinitrate Yes PHC and Hosp EDL C01DA14 Isorbide mononitrate Yes PHC and Hosp EDL Nitrofuran derivatives J01XE01 Nitrofurantoin Yes Hosp EDL Nitroimidazole derivatives P01AB01 Metronidazole Yes All EDL (agents against amoebiasis and other P01AB02 Tinidazole Yes All EDL protozoal diseases)

Ophthalmic preparations S01GA04 Oxymetazoline Yes All

S01FB01 Phenylephrine Yes Hosp EDL

S01GX01 Sodium Cromoglycate Yes PHC and Hosp

EDL

S01AA01 Chloramphenicol Yes All EDL

S02AA01

S03AA08

S01JA01 Fluorescein Yes Hosp EDL S01HA02 Oxybuprocaine Yes Hosp EDL S01AA11 Gentamycin Yes Paeds EDL S03AA06 S01XA20 Liquid lanolin, anhydrous Yes Hosp EDL Other Beta-lactam J01DB04 Cefazolin Yes Hosp and Paeds antibacterials Cephalosporins (First, second, third and fourth J01DD04 Ceftriaxone Yes All EDL generations) J01DB01 Cephalexin Yes PHC and Paeds EDL J01DD02 Ceftazidime Yes Hosp and Paeds EDL J01DD01 Cefotaxime Yes Paeds

Page 46 of 109

Otologicals S02AA10 Acetic Acid Yes PHC and Hosp EDL S02AA30 Bismuth iodoform paraffin paste Yes Paeds EDL

Oxazolidinone J01XX01 Fosfomycin Yes Hosp EDL antibacterial Oxytocic ergot alkaloids G02AB03 Ergometrine PHC and Hosp EDL Prostaglandins G02AD02 Dinoprostone Yes Hosp and Paeds EDL A02BB01 Misoprostol Yes PHC and Hosp G02AD06 EDL G02AD01 Dinoprost (prostaglandin E2) Yes Hosp EDL A02BC02 Pantoprazole Hosp EDL Proton pump inhibitors (PPIs) Psychostimulant N06BA04 Methylphenidate Yes Paeds EDL Quaternary ammonium A03BB01 Hyoscine butylbromide Yes All EDL compound antispasmodic N06AB03 Fluoxetine Yes All EDL Sulfonylureas A10BB01 Glibenclamide All EDL A10BB09 Gliclazide PHC and Paeds EDL A10BB12 Glimepiride All EDL Sulphonamides and J01EE01 Co-trimoxazole Yes All EDL Trimethoprim combination antibacterial Tetracycline antibacterials J01AA02 Doxycycline Yes All EDL

Topical anal preparations C05AD01 Lidocaine Yes PHC EDL A07BB Bismuth preparation Yes PHC EDL

Vaccines EPI vaccines (Extended Yes All EDL Program on Immunization) J07BM01 HPV Yes PHC EDL J07BB01 Influenza Yes All EDL J07BB02 J07BB03 J07AL01 Pneumococcal (adult) Yes Hosp and Paeds J07AL02 EDL J07BG01 Rabies Yes All EDL

J07BK01 Varicella Zoster Yes Paeds EDL J07BK02 J07BK03 J07AH07 Meningococcal conjugate Yes Paeds EDL J07AH08 Vitaminutes and minerals A11HA02 Pyridoxine Yes All EDL A11CA Vitamin A Yes PHC and Paeds EDL

Page 47 of 109

A11EA Vitamin B complex Yes PHC Hosp EDL B02BA01 Vitamin K Yes All EDL B02BA02 B03BA01 Vitamin B12 Yes All EDL B03BA02 B03BA03 B03BA04 B03BA05 B03BA51 B03BA53 A12CB Zinc Yes PHC and Paeds EDL A11DA Thiamine/ Vit B1 Yes All EDL A11HA01 Nicotinamide Yes PHC and Hosp EDL A12AA03 Calcium gluconate Yes All EDL B03BB01 Folate All EDL A11BA Multivitamin PHC and Paeds EDL Xanthine derivatives R03DA05 Aminophylline Yes Paeds EDL R03DA04 Theophylline Yes Hosp EDL

10.2 Medical and Surgical Management 48. The previous section outline drugs for the management of acute and chronic conditions. The following section outlines medical and surgical management of acute and chronic conditions. As with diagnostic services and medicines these interventions are recommended for a specified clinical indication and not merely as a routine care. The following services are proposed: • Pregnancy: Labour and delivery; complications of pregnancy • Mental Health Services • Eye Health services • Oral Health services • Skin • Musculoskeletal • Urogenital

10.2.1 Labour and Delivery 49. Table 8 outlines maternal services during labour and delivery (antenatal services included in preventative package). Labour and delivery services by a doctor or midwife is proposed. Global obstetric care and midwife delivery for intrapartum and postpartum up to 6 weeks are proposed. The services include all care during

Page 48 of 109

labour and delivery. Guidelines on labour and delivery and management of complications of pregnancy is included in the STGs.

Table 8: Labour and delivery services Category of Interventions and Description Codes Services and Services Interventions Labour and Delivery by Doctor Obstetric care for vaginal Global obstetric care which 2614 delivery and obstetric includes delivery and obstetric care from care commencement of labour until after post-partum (6 weeks) Obstetric care for Global obstetric care which caesarean section and includes caesarean section obstetric care from the (where clinically indicated) commencement of labour delivery and obstetric care until after the postpartum visit (6 weeks visit). Intrapartum obstetric All modes of delivery (including 2616 care Caesarean) All inductions of labour (medical or surgical) Intrapartum paracervical and pudential blocks Intrapartum amnioscopy Foetal blood sampling Application of scalp leads Symphysiotomy Manual removal of placenta Repair cervical tears Correction of uterine inversion Drainage of vulva haematoma Repair third degree tear Repair second degree tear Repair Episiotomy Resuscitation of new-born by obstetrician Tracheal intubation o Missed confinement Prevention of post-partum haemorrhage Caesarean-hysterectomy 2653 Post-partum 2657 hysterectomy Abdominal operation for 2669 ruptured gravid uterus: Repair

Page 49 of 109

Labour and Delivery by Midwife Global midwife delivery Includes all care from the time 399 of admission of the patient in labour until discharge from hospital. First Stage Monitoring 400 Second and Third stage 401 labour. Vaginal delivery including episiotomy/tear and repair and general obstetric care. Fourth Stage Monitoring 402

Visit to patient during first 406 stage labour (may not be charged in conjunction with item 400) Global fee for childbirth 407 education. Assisting at delivery (if a 410 medical practitioner is requested to take over delivery due to complications during a home delivery) Post-natal visits 421 (excluding postnatal exercises), per visit Cardiotocography 404

Care and examination Obstetric care 6 weeks Routine care and exam of 2614 after birth postpartum mothers Management of complications: Postpartum haemorrhage Puerperal sepsis Cracked nipples during breastfeeding Mastitis According to national guidelines Antepartum depression Postpartum depression Postpartum psychosis According to most recent national guidelines New-born services New-born attendance: Routine care and assessment of 107 Exclusive attendance to the new-born immediately after baby at Caesarean birth: according to most recent section, normal delivery new-born national guidelines or visit in the ward Management of neonatal conditions:

Page 50 of 109

Birth asphyxia and resuscitation Neonatal jaundice Congenital pneumonia Neonatal apnoea Neonatal convulsions Hypothermia According to most recent national guidelines New-born attendance: 113 Emergency attendance to new-born at all hours Phototherapy, per day 405

10.2.2 Management of complications of pregnancy 50. Table 9 outlines proposed procedures related to ectopic pregnancy, incomplete abortion and termination of pregnancy. Guidelines on management of complications of pregnancy is included in the STGs.

Table 9: Management of complications of pregnancy Category Intervention/Services Description Codes

Ectopic pregnancy 2489 under 12 weeks (salpingectomy) Ectopic pregnancy 2490 under 12 weeks (salpingostomy) Ectopic pregnancy - 2491 after 12 weeks Dilatation and curettage 2443 (D&C) (excluding after- care) Fractional dilatation and Pregnancy with abortive 2444 curettage (D&C) outcome (excluding after-care) Evacuation of uterus: Pregnancy with abortive 2445 Incomplete abortion: outcome Before 12 weeks gestation Evacuation of uterus, Pregnancy with abortive 2447 incomplete abortion: outcome After 12 weeks gestation Termination of Termination of pregnancy 2448 pregnancy before 12 weeks Evacuation: Missed Missed abortion 2449 abortion: Before 12 weeks gestation Evacuation: Missed Missed abortion 2451 abortion: After 12 weeks gestation

Page 51 of 109

Termination of Termination of pregnancy 2452 pregnancy after 12 weeks - administration of intra/extra amniotic prostaglandin Evacuation uterus post- 2455 partum

10.2.3 Mental Health Services 51. Mental health services aim to prevent, manage and rehabilitate mental health conditions. The proposed mental health services include the following: Preventive services (see preventative services);

• Prevention of mental health conditions which includes screening, education and awareness in maternity, new-borns, children, adults and the elderly. • Age appropriate screening methods should be used. Management services; • Comprehensive mental health assessment for identified or referred cases. Comprehensive assessments should include all clinical tests required to exclude or diagnose conditions per accepted clinical criteria (value-based care/outcome measures/QOL - clinical measures). Management of mental health conditions should be evidence based biopsychosocial interventions based on national guidelines and clinical pathways (see standard treatment guidelines)(35). Rehabilitation services (see rehabilitation services); • Appropriate day care/residential care should be included to avoid unnecessary hospitalisations (see rehabilitation services)

10.2.4 Eye health services 52. The Global action plan 2014-2019 envisions a world in which nobody is needlessly visually impaired, where those with unavoidable vision loss can achieve their full potential, and where there is universal access to comprehensive eye care services. Services for eye health are proposed in table 10. The service includes consultations; diagnostic procedures specific to eye health, therapeutics as well as lenses. 53. Two major types of eye and vision consultations are proposed. Firstly, routine annual comprehensive eye and vision examination and secondly, the priority-focused eye and vision examination. The comprehensive eye and vision examination are recommended for optimising visual function through diagnosis, treatment and management of refractive, ocular motor, accommodative and binocular vision problems. It also aims to enhance the quality of life by preventing and/or minimising vision loss; detecting systemic disease and

Page 52 of 109

managing ocular sequelae as well as referral for appropriate care, counselling and educating patients on current conditions and preventive care; to maintain ocular and systemic health and visual function. Comprehensive eye and vision examinations are proposed at least every two years for asymptomatic, low- risk persons aged 18 to 39 years to evaluate changes in eye and visual function, and to provide for early detection of sight-threatening eye and systemic health problems. 54. The priority-focused eye and vision examination is specific to a particular problem that is addressed urgently including but not limited to: foreign body removal, eye infections and inflammation and chemical and thermal injuries.

Table 10: Eye Health Services Category Interventions Description Code Frequency and Services Consultation In this category, only one code can be billed at a time. These can be charged with any of the diagnostic and therapeutic codes that can also be done in isolation Optometric A comprehensive 11001 6 months Examination (incl. examination to Tonometry) manage refractive conditions. Optometric A comprehensive 11081 6 months Examination & examination to Visual Fields manage refractive conditions. Optometric-Re- Follow-up 11021 6 months examination Consultation :15 11041 6 months min. without performing Optometric Exam. Pathology Priority focused 11161 Clinical need examination examination. No refraction Diagnostic These procedures Procedures can be done in combination with 11001, 11081 etc or in isolation Cycloplegic Children with 11303 6 months Refraction myopia and strabismus or latent

Page 53 of 109

hyperopia suspected and accommodative abnormalities Preferential 11323 Looking (Infants < Two Years and non-communicable) Corneal For irregular 11346 12 months Topography astigmatism, Keratoconus, advance contact lens fittings corneal dystrophies Gonioscopy As prerequisite for 11356 12 months code 11366 Visual Field Cannot be charged 11423 12 months with 11001, 11081, 11021 Threshold Visual 11443 12 months Fields Evaluation of 11246 12 months Colour Vision Evaluation of 11283 12 months Lacrimal System Photography of 11624 12 months Fundus Dilated fundus Mandatory for over 11366 12 months examination 40 years and when indicated Therapeutics These procedures can be done in combination with 11001, 11081 etc or in isolation Removal of Foreign Indicated when 15004 Usually emergency body Corneal with foreign object is slit lamp lodged into cornea Removal of Foreign Indicated when 15000 Usually emergency body External eye foreign object is Conjunctiva lodged into conjunctiva Screening School 11809 (per hour) Contact Lens These procedures Procedures can be done in combination with 11001, 11081 etc or in isolation Simple Contact Soft lenses - High 12032 soft lenses Lens evaluation - scripts prescribed for per visit Including myopia significant control in children refractive error

Page 54 of 109

Complex Contact Contact Lens 12052 Irregular corneal Lens evaluation - Consultation topography and per visit (Complex) RGPs, ectasia warrant Hybrids complex contact lens designs and management CL Dispensing 12072 Care of advanced and/or Assessment lens designs Binocular These procedures Vision/Orthoptics and can be done in visual training combination with 11001, 11081 etc or in isolation Binocular Vision /Orthoptics Evaluation of Evaluation for non- 13023 As per indication Binocular Instability strabismic, Complex Case convergence and accommodative abnormalities Visually Related Evaluation of Evaluation of 13105 As per indication learning Disorders Visually Related children with vision Learning Disorders developmental, -including Reading learning and other rate test related disorders Visual Training Indication for all 13423 As per indication Individual (per 15 therapy codes minutes) Amblyopia, strabismus, Convergence abnormalities, Accommodative abnormalities Visual Training As per 13423 13445 As per indication Individual (per 30minutes) Visual Training As per 13423 13463 As per indication Group per Patient (per 15 minutes) Visual Training As per 13423 13489 As per indication Away from Practice Low Vision These procedures Assessment & can be done in Training (per Half combination with hour) code 11001, 11081 etc or in isolation Simple LV Assessment of 16013 As per indication Assessment persons with high refractive errors and conditions leading to reduced functional vision Complex LV As per 16013 16033 As per indication Assessment

Page 55 of 109

Simple LV Training As per 16013 16073 As per indication

Complex LV As per 16013 16093 As per indication Training Reports etc Report at request 19001 of Medical Aid Lenses and Devices Generic Lenses Frames Frames 40501 As per indication Single Vision lens Correcting 81BS001 As per indication Refractive errors Special Vision High Correcting 82BS001 As per indication Powers Refractive errors Bifocal- Correcting 84BS001 As per indication Round/flat/top Seg Refractive errors 74*28 Seg Varifocal Distance Correcting 86BS001 As per indication to near Refractive errors Varifocal Correcting 85BS001 As per indication Intermediate to Refractive errors Near Accommodative Correcting 83BS001 As per indication support lens Refractive errors All other codes 99999

Specialised CLs Hard Contact Correcting 24022 As per indication Lenses Refractive errors in specific circumstance Scleral Contact Correcting 24024 As per indication Lenses Refractive errors in specific circumstance Generic Soft Correcting 27001 As per indication Spherical High Rx Refractive errors in Contact lens specific circumstance Generic Soft Toric Correcting 27031 As per indication High Rx contact Refractive errors in lens specific circumstance Generic Soft Correcting 27051 As per indication Conventional High Refractive errors in RX Toric specific circumstance

Low Vision Devise Low Vision Aid – Correcting errors of 61013 As per indication Single Element refraction and conditions leading to LV

Page 56 of 109

Low Vision Aid – Correcting errors of 61114 As per indication Multiple Elements refraction and Fixed Focus conditions leading to LV Low Vision Aid – Correcting errors of 61215 As per indication Multiple Elements refraction and Variable Focus conditions leading to LV Low Vision Aid – Correcting errors of 61318 As per indication Electronic refraction and conditions leading to LV Dispensing Fees Dispensing Fee – 11501 If Indicated Single Vision Dispensing Fee – 11521 If Indicated Bifocals Dispensing Fee – 11541 If Indicated Varifocals Optometry related Add-ons to basic As per document products materials, PMB – A case for specialized devices optometry and accessories

10.2.5 Oral Health Services 55. WHO defines oral health as essential to general health and well-being, greatly influencing quality of life. It is defined as a state of being free from mouth and facial pain, oral diseases and disorders that limit an individual's capacity in biting, chewing, smiling, speaking and psychosocial well-being(36). The World Dental Federation (FDI) recently adopted a new definition of oral health as multi-faceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and convey a range of emotions through facial expressions with confidence and without pain, discomfort and disease of the craniofacial complex(37). The National Policy for Oral Health (NPOH) has as its goal, the promotion of the oral health of the population of South Africa by preventing and restricting oral diseases in order to ensure optimum oral health. The underlying philosophy of this policy is based on the Primary Health Care approach. 56. Oral health care services are usually classified into 5 major types (plus emergency care): i. Oral Health Promotion – these services include diet counselling, smoke and alcohol cessation programs etc., these services focus on oral health and general health and do not involve clinical care. ii. Preventive care – are clinical procedures aimed at preventing the occurrence of diseases, sometimes called specific protection. Examples include scaling and polishing, fissure sealants, professional fluoride application etc.

Page 57 of 109

iii. Basic or General Dental Care – this type of care includes extractions or fillings. Root canals may or may not be included in this level of care. iv. Major Dental Care (Specialised) - crowns, implants, dentures, bridges orthodontic treatment (where indicated). v. Cosmetic Dental Care – tooth whitening, veneers, and orthodontics (expect appliances to correct congenital abnormalities). vi. Emergency Dental Care - this includes: - dental emergencies, i.e. those requiring immediate attention in order to minimise the risk of serious medical complications or prevent long-term dental complications. These procedures are normally undertaken in an emergency department. - dental Unscheduled (urgent), care provided for the relief of pain and sepsis not responsive to over-the counter medicines and other interventions. - non- urgent care, normally patients present with fractured denture, dislodged bridge or crown, impacted (painless molars). This type of care is not classified as emergency or urgent care. 57. The following guiding principles underpin the proposed service package: • Treatment performed should lead to or be part of comprehensive oral rehabilitation and maintenance. • The treatment should be based on clinical need, scientific evidence and national guidelines. • The treatment provided should have impact, including desired clinical outcomes, financial benefits and patient satisfaction.

Table 11: Oral health services Categories Intervention/Services Description Code Frequency Consultations Comprehensive oral Management of presenting 8102 24 months examination problems only for Modification of help-seeking dentists behaviours Management of continuing problems Opportunistic health promotion. Oral examination 8101 12 months only for Dental Therapists, Oral Hygienists Limited oral examination 8104

Page 58 of 109

Periodontal examination Periodontal examination 8176 Once in 24 includes but is not limited months or to a periodontal charting of after review the complete dentition; yearly if plaque index and bleeding justified, index. The findings should above the age be recorded, is a part of the of 15 years patient’s clinical record and should be retained by the oral hygienist. This code should not be used concurrent with any other oral examination codes. Consultation - second For referral 8190 opinion or advice

Dental prophylaxis Prophylaxis - complete Services/procedures 8159 dentition, scaling, polishing intended to eliminate or 8155 and (remineralising agent - reduce the need for future fluoride dental treatment. Removal of gross calculus 8160 Prophylaxis - complete 8180 dentition (periodontally 8179 compromised patient) Nutritional counselling: 8149 consultation Tobacco counselling: 8150 consultation Oral hygiene instruction 8151 8153 Dental sealant 8163 Occlusal guard 8169 Mouth guard 8171 Oral hygiene instruction 8177 (periodontally 8178 compromised patient) Diagnostic Imaging Intraoral radiograph - Diagnostic 8107 periapical radiographs/diagnostic Intraoral radiographs - images include 8108 As part of complete series interpretation. comprehensiv Radiographs/diagnostic e images should only be taken examination, for clinical reasons as 24 months Intraoral radiograph - determined by the dentist 8112 bitewing and practitioners should Intraoral radiograph - comply with the Regulations 8113 When occlusal concerning safe radiological clinically practice and take the indicated Extraoral radiograph - necessary precaution to 8114 When hand-wrist minimise radiation of clinically patients. indicated

Page 59 of 109

Extraoral radiograph - Radiographs/diagnostic 8115 24 months panoramic images are part of the unless patient's clinical record, clinically should be of diagnostic indicated Extraoral radiograph - quality, properly identified 8116 When cephalometric and dated. The dentist clinically should retain the original indicated Extraoral radiograph - images and only copies 8118 When skull/facial bone should be used to fulfil clinically requests made by patients or indicated Oral and/or facial image third-party funders. A 8121 (digital/conventional) complete series of intra-oral Other diagnostic radiographs/images for procedures diagnostic purposes is Diagnostic models required once per treatment 8117 Consider plan only. A second series digital may be required in diagnostic exceptional cases e.g., models 8126, following periodontal 2 years Diagnostic models surgery. The same applies to 8119 mounted panoramic films, where Digital diagnostic models additional films may be 8126 Pulp tests required for follow-up/re- 8124 Tracing and analysis of evaluation purposes. 8811 extra-oral film Diagnostic radiographs/diagnostic images preceding endodontic treatment, periodontal treatment, the surgical extraction of teeth or roots and fixed prostheses are fundamental to ethical clinical practice. Restorative Services Amalgam Restorations 8341 3 years 8342 8343 8344 Resin-based Composite 8350 3 years Restorations 8351 8352 8353 8354 8367 8368 8369 8370 Isolation of teeth Isolation with resin 8304 restorations will improve longevity of restorations and allow for benefit to reduce to once every 5 years in the future Emergency crown (chair- 8137 side)

Page 60 of 109

Prefabricated metal crown 8357 Once per lifetime per tooth, only on deciduous teeth Prefabricated resin crown 8375 Once per lifetime per tooth, only on deciduous teeth Pin Retention and Cores Pin retention - first pin (in 8347 3 years, addition to restoration) check data Pin retention - each 8348 3 years, additional pin (in addition check data to restoration) Recement inlay, onlay, 8133 crown or veneer Remove inlay, onlay or 8135 crown Remove retention post 8138 (prefabricated or cast) Carve restoration to 8349 accommodate existing removable prosthesis Repair crown (permanent 8413 or provisional) Endodontic Services Root Canal treatment Evidence on retreatments, other treatment example extractions. Add 8334

Pulp cap - direct Services/procedures 8301 Possibility of intended to treat diseases of deleting, the dental pulp and their evidence plus sequelae. costing Pulp cap - indirect 8303 6 weeks Pulp amputation 8307 (pulpotomy) Pulp removal (pulpectomy) 8132 Endodontic Therapy Root canal preparatory Includes endodontic therapy 8332 visit on primary teeth. Does not 8333 include diagnostic evaluation and necessary radiographs/ diagnostic images. Limitation: Intra-operative radiographs/ diagnostic images are limited to three on a single canal tooth and five on a multi-canal tooth for

Page 61 of 109

each completed endodontic therapy. Report code 8304 (application of a rubber dam) in addition to these codes. Obturation of root Canals 8335 8328 8336 8337 Root canal therapy - Codes 8329, 8338, 8339 and 8338 anteriors and premolars - 8340 (endodontic treatment 8329 first canal completed at a single visit) 8339 may not be used with codes 8340 8332, 8333 and 8334 8631 (endodontic preparatory 8633 visits and re-preparation of previously obturated canal). Apexification/recalcification 8635 – per visit Periodontics Services Wedge resection (isolated 8763 procedure) Non-surgical periodontal services Provisional splinting - 8723 ICD 10 code, extracoronal (wire) - per material cost sextant Provisional splinting - 8725 ICD 10 code, extracoronal (wire plus material cost resin) - per sextant Root planning 8737 12 months 8739 unless clinically indicated Unlisted periodontal Descriptor not covered by 8768 procedure other procedures. Allowance for new technology and changes in evidence Unlisted oral medicine Descriptor, not covered by 8787 procedure other procedures Removable Prosthodontics Complete dentures - 8231 5 years maxillary and/or 8232 mandibular 8643 8651 8649 8645 Immediate denture – Only repairs and relines. No 8244 Review maxillary/mandibular conventional denture for 1 8245 evidence. year Partial denture - resin base 8233 5 years 8234 8235 8236

Page 62 of 109

8237 8238 8239 8240 8241 Adjust complete or partial 8275 5 years denture Adjust complete or partial 8662 5 years dentures (remounting) Repair denture or other 8269 5 years intra-oral appliance Add clasp to existing 8270 5 years partial denture Add tooth to existing partial 8271 5 years denture Impression to repair or 8273 5 years modify a denture or other intra-oral appliance Rebase – The partial or 5 years complete removal and replacement of the denture base. Rebase complete or partial 8259 5 years denture (laboratory) Remodel complete or 8261 5 years partial denture Reline complete or partial 8263 5 years denture 8267 Interim dentures Clasp or rest - stainless 8255 steel Bar - lingual or palatal 8257 Tissues conditioning per 8265 arch (including soft self- cure reline) Precision attachment 8599 (removable denture) Overdenture 8652 8653 Soft base to denture (heat 8667 Clear cured) indications Maxillary prosthesis Obturator prosthesis, Simple obturator 9101 surgical - modified denture Neonatal prosthesis Feeding aid prosthesis, 9119 neonatal Trismus appliances Trismus appliance 9167 9168 Other fixed prosthodontic procedures Recement bridge 8514

Page 63 of 109

Remove bridge 8516 Sectioning of a bridge 8515 Oral and Maxillo- facial Surgery Extraction - tooth or 8201 exposed tooth roots 8202 Surgical removal of 8213 residual roots 8214 Surgical removal of tooth 8937 fully erupted Surgical removal of 8941 impacted tooth 8943

Reimplantation of avulsed 8517 tooth (include stabilisation) Oral antral fistula closure 8909 Caldwell-Luc procedure 8911 Biopsy of oral tissue - soft 8917 Surgical exposure of 8981 impacted or unerupted teeth to aid eruption Surgical excision Excision of benign soft 8971 tissue tumour/cyst requiring minimal or no suturing Incision & drainage of 8731 abscess 9011 9013 Dento-alveolar fracture - 9024 per sextant Mandibular fractures Mandible fracture – closed 9025 reduction Manipulation and 9282 immobilisation of nasal fracture Treatment of MPDS Diagnosis symptomatic 8850 treatment and refer 8851 Reduction of TMJ 9085 dislocation 9087 9089 Repair of traumatic wounds Suture - minor Repair of traumatic wounds 8192 excludes surgical procedures Complicated suturing Reconstruction requiring delicate handling of tissues and undermining for meticulous closure. Excludes the closure of surgical incisions. Frenulectomy/frenulotomy 8985

Page 64 of 109

Osteotomy - segmented, 9055 posterior Osteotomy - segmented, 9057 anterior Glossectomy - partial 9069 Orthodontic Services Ortho Tx 8862 8863 Ortho Tx - functional 8858 appliance Fixed Appliance Therapy – Partial Ortho Tx - partial fixed 8861 appliance - minor 8865 8866 Repair orthodontic 8846 appliance 8847 8848 Supplementary Services Anaesthesia 8141 8143 8145 Professional Visits 8129 8140 Drugs, Medicaments and 8109 Materials 8110 8183 8220 8304 8306 Administrative and 8099 laboratory services 8106 8111 8120 Miscellaneous Services Palliative Treatment Emergency dental 8131 treatment Application of desensitising 8166 resin, per tooth Application of desensitising 8167 medicament, per visit Sedative filling 8165 Treatment of post- 8931 extraction haemorrhage Treatment of septic socket 8935 Internal bleaching 8325 8327 Enamel microabrasion 8158 Behaviour management Paediatric cases /adult 8168 anxious patients Occlusal adjustment - 8553 minor

Page 65 of 109

Table 12: Procedures Category Service/Intervention Description Service Code Medical procedures Setting of sterile tray: A fee of Out-patient 0202 10,00 clinical procedure units may be charged for the setting of a sterile tray where a sterile procedure is performed in the rooms. Cost of stitching material, if applicable, shall be charged for according to item 0201, as appropriate Intravenous treatment: Out-patient 0205 Intravenous infusions (cut-down or push-in) (patients under three years): Cut-down and/or insertion of cannula - chargeable once per 24 hours Intravenous treatment: Out-patient 0206 Intravenous infusions (push-in) (patients over three years): Insertion of cannula - chargeable once per 24 hours Venesection: Therapeutic Out-patient 0208 venesection (Not to be used when blood is drawn for the purpose of laboratory investigations) Allergy: Patch tests: First patch Out-patient 0217 Allergy: Skin-prick tests: Skin- 0218 prick testing: Insect venom, latex and drugs Allergy: Patch tests: Each 0219 additional patch Allergy: Skin-prick tests: 0220 Immediate hypersensitivity testing (Type I reaction): Per antigen: Inhalant and food allergens Allergy: Skin-prick tests: Delayed 0221 hypersensitivity testing (Type IV reaction): Per antigen Special treatment of severe acne Out-patient 0227 cases, including draining of cysts, expressing of cleaning of Comedones and/or steaming, abrasive cleaning of skin and UVR per session Nebulisation (in rooms) Out-patient 1136/88050

Page 66 of 109

Flow volume test: Out-patient 1186 Inspiration/expiration Flow volume test: Out-patient 1188 Inspiration/expiration/pre- and post-bronchodilator (to be charged for only with first consultation - thereafter item 1186 applies) Flow volume test: Out-patient 1188 Inspiration/expiration/pre- and post-bronchodilator (to be charged for only with first consultation - thereafter item 1186 applies) Forced expirogram only Out-patient 1189

Peak expiratory flow only Out-patient 1192/88052

Prolonged neonatal resuscitation Out-patient 1227

General Practitioner's fee for the Out-patient 1228 taking of an ECG only: Without effort: ½ (item 1232) General Practitioner's fee for the Out-patient 1229 taking of an ECG only: Without and with effort: ½ (item 1233) Electrocardiogram: Without effort Out-patient 1232

Electrocardiogram: With and Out-patient 1233 without effort Multi-stage treadmill test Out-patient 1235

Electrocardiogram without effort: Out-patient 1236 Under 4 years old 24 Hour ambulatory blood Out-patient 1237 pressure: Hire fee 24 Hour ambulatory ECG Out-patient 1238 monitoring (holter): Hire fee 24 Hour ambulatory ECG Out-patient 1239 monitoring (holter): Interpretation Electrodesiccation: Limited Out-patient 2129 number Electrodesiccation: multiple In patients 2131 extensive Insertion of intra uterine In/Out-patient 2442 contraceptive device (IUCD) (excluding after-care) Implantation hormone pellets Code (excluding after-care) Taking of blood for testing in 0210 laboratory Therapeutic thoracentesis 1145

Page 67 of 109

Therapeutic abdominal 1803 paracentesis Bladder catheterisation: Male (not 1996 an operation) Bladder catheterisation: Female 1997 (not an operation) Tracheostomy care. 88051

Stomal irrigation - 60 minutes. 88079 May not be used in conjunction with the global fees. Nasogastric tube insertion, 88080 feeding and removal. Colonic lavage 88081

Enema administration 88082

Aspiration of stomach/gastric 88083 lavage. Faecal impaction/manual 88084 removal. Any urinary tract procedure 88090 including catheterisation, bladder stimulation and emptying. Condom catheter application, 88091 penile dressing, catheter care including bag change or catheter removal. Incontinence management (30 88093 minutes) This fee includes intermittent catheterisation, external sheath drainage, taking of history, providing literature and teaching. Simple stoma - a well- 88200 constructed, sited stoma which is easy to pouch. Very little or no peristomal skin excoriation. Complex stoma - a poorly 88201 constructed, non-sited stoma requiring convexity or build up. Difficult to pouch. Severe peristomal skin excoriation. Moderate stoma - a fairly well 88202 constructed, sited stoma which may require straight forward convexity or build up. Mild to moderate peristomal skin excoriation. Stoma products charged in 88205 accordance with rule 05. Consumables used, and charged 88301 according to rule 05

Page 68 of 109

Equipment hire per day, charged 88302 according to rule 06. Treatment of simple 88040 wounds/burns requiring dressing only. Treatment of extensive 88041 wounds/burns requiring extensive nursing management e.g. irrigation, etc. Treatment of moderate 88042 wounds/Burns e.g. drains or fistulas and inserting of sutures Tracheostomy care. 88051

Skin

Laceration, tumours, cysts, and other skin lesions Biopsy without suturing: First Out-patient 0233 lesion Biopsy without suturing: Out-patient 0234 Subsequent lesions (each) Biopsy without suturing: Out-patient 0235 Maximum for multiple additional lesions Deep skin biopsy by surgical 0237 incision with local anaesthetic In/Out-patient and suturing Treatment of benign skin lesion Out-patient 0241 by chemo-cryotherapy: First Lesion Treatment of benign skin lesion Out-patient 0242 by chemo-cryotherapy: Subsequent lesions (each) Treatment of benign skin lesion Out-patient 0243 by chemo-cryotherapy: Maximum for multiple additional lesions Removal of benign lesion by Out-patient 0245 curretting under local or general anaesthesia followed by diathermy and curretting or electrocautery: First lesion Removal of benign lesion by Out-patient 0246 curretting under local or general anaesthesia followed by diathermy and curretting or electrocautery: Subsequent lesions (each) Drainage of subcutaneous In/Out-patient 0255 abscess onychia, paronychia, pulp space or avulsion of nail

Page 69 of 109

Removal of foreign body In/Out-patient 0259 superficial to deep fascia (except hands) Stitching of soft-tissue injuries: In/Out-patient 0300 Stitching of wound (with or without local anaesthesia): Including normal after-care) Stitching of soft-tissue injuries: In/Out-patient 0301 Additional wounds stitched at same session (each) Needle biopsy - soft tissue Out-patient 0305 Excision and repair by direct In/Out-patient 0307 suture; excision nail fold or other minor procedures of similar magnitude Each additional small procedure Out-patient 0308 done at the same time Fine needle aspiration for soft Out-patient 0316 tissue (all areas) Aspiration of cyst or tumour Out-patient 0317 Joint: Dislocation: Shoulder Casualty rooms, 0549 Severe cases- surgical treatment In-hospital

In/Out-patient Aspiration of joint or intra-articular 0661 injection (not including after-care) (modifier 0005 not applicable) Limb cast (excluding after-care) 0887 (modifier 0005 not applicable) Removal of foreign bodies 0922 requiring incision: Under local anaesthetic Removal of foreign bodies from 1063 nose: At rooms Septum abscess: At rooms, 1077 including after-care Opening of quinsy: At rooms 1107 Repair of skin laceration lid: refer to eye care Code Simple basket Diathermy to wart on lid margin 3167 Debridement and closure of In/Out-patient Code injuries Radical excision of nailbed Theatre/in/out 0310 hospital Excision of large benign tumour In-patient (more than 5 cm) 0311

Destruction of In/Out-patient 2125 condylomata/chemo- or cryotherapy: Limited number (see item 2317) Removal of tag or polyp In/Out-patient 2271

Page 70 of 109

Removal of small superficial Out-patient 2272 benign lesions Cryo- or electro-cauterisation, Out-patient 2392 (excluding cost of disposable loop electrode): In consulting room Punch biopsy (excluding after- Out-patient 2399 care) Ear, Nose & Throat

Laryngeal intubation In/Out-patient 1117 Tracheostomy In/Out-patient 1127 Ludwig's Angina: Drainage In/Out-patient 1110 Post tonsillectomy or Assess, stabilise and 1111 adenoidectomy haemorrhage refer Removal of foreign bodies Assess, stabilise and 0922 requiring incision: Under local refer anaesthetic Removal of foreign bodies from Out-patient 1063 nose: At rooms Septum abscess: At rooms, Out-patient 1077 including after-care Opening of quinsy: At rooms Out-patient 1107 Chest Paracentesis chest: Diagnostic In/out-patients 1143 Paracentesis chest: Therapeutic In/Out-patient 1145 Urogenital Percutaneous aspiration of In/Out-patient, or 1995 bladder casualty Bladder catheterisation: Male (not In/Out-patient, or 1996 at operation) casualty Bladder catheterisation: Female In/Out-patient, or 1997 (not at operation) casualty Puncture aspiration hydrocele In/Out-patient, or 2183 with or without injection of casualty medication Orchidectomy (total or Assess, stabilise and 2191 subcapsular): Unilateral refer Orchidectomy (total or Assess, stabilise and 2193 subcapsular): Bilateral refer Suprapubic cystostomy Assess, stabilise and 2015 refer Operation for torsion, appendix, Assess, stabilise and 2187 testis refer Operation for torsion testis with Assess, stabilise and 2189 fixation of contralateral testis refer

Circumcision: Clamp procedure In/Out-patient 2133 Circumcision: Surgical excision In/Out-patient 2137 other than by clamp or dorsal slit, any age Vasectomy: Unilateral or bilateral In-patient 2207 (no extra fee to be charged if

Page 71 of 109

done in combination with prostatectomy) Rubber band ligation of Rooms/ Hospital 1719 haemorrhoids: Per haemorrhoid procedure rooms Drainage of external thrombosed 1725 pile Excision of anal skin tags In/Out-patient 1729

Musculoskeletal Fracture (reduction under general Assess, stabilise and 0383 anaesthetic): Scapula refer

Fracture (reduction under general Assess, stabilise and 0387 anaesthetic): Clavicle refer

Percutaneous pinning of Assess, stabilise and 0388 supracondylar fracture: Elbow - refer standalone procedure Fracture (reduction under general Assess, stabilise and 0389 anaesthetic): Humerus refer Fracture (reduction under general Assess, stabilise and 0391 anaesthetic): Radius and/or Ulna refer Fracture (reduction under general Assess, stabilise and 0392 anaesthetic): Open reduction of refer both radius and ulna (modifier 0051 not applicable) Fracture (reduction under general Assess, stabilise and 0402 anaesthetic): Carpal bone refer Fracture (reduction under general Assess, stabilise and 0403 anaesthetic): Bennett fracture- refer dislocation Fracture (reduction under general Assess, stabilise and 0405 anaesthetic): Open treatment of refer metacarpal: Simple Fracture (reduction under general Assess, stabilise and 0409 anaesthetic): Finger phalanx: refer Distal: Simple Fracture (reduction under general Assess, stabilise and 0411 anaesthetic): Finger phalanx: refer Distal: Compound Fracture (reduction under general Assess, stabilise and 0413 anaesthetic): Proximal or middle: refer Simple Fracture (reduction under general Assess, stabilise and 0415 anaesthetic): Proximal or middle: refer Compound Fracture (reduction under general Assess, stabilise and 0417 anaesthetic): Pelvis fracture: refer Closed Fracture (reduction under general Assess, stabilise and 0419 anaesthetic): Pelvis: Operative refer reduction and fixation

Page 72 of 109

Fracture (reduction under general Assess, stabilise and 0421 anaesthetic): Femur: Neck or refer Shaft Fracture (reduction under general Assess, stabilise and 0425 anaesthetic): Patella refer Fracture (reduction under general Assess, stabilise and 0429 anaesthetic): Tibia with or without refer fibula Fracture (reduction under general Assess, stabilise and 0433 anaesthetic): Fibula shaft refer Fracture (reduction under general Assess, stabilise and 0435 anaesthetic): Malleolus of ankle refer Fracture (reduction under general Assess, stabilise and 0437 anaesthetic): Fracture-dislocation refer of ankle Fracture (reduction under general Assess, stabilise and 0438 anaesthetic): Open reduction refer Talus fracture (modifier 0051 not applicable) Fracture (reduction under general Assess, stabilise and 0439 anaesthetic): Tarsal bones refer (excluding talus and calcaneus) Fracture (reduction under general Assess, stabilise and 0440 anaesthetic): Open reduction refer Calcaneus fracture (modifier 0051 not applicable) Fracture (reduction under general Assess, stabilise and 0441 anaesthetic): Metatarsal refer Fracture (reduction under general Assess, stabilise and 0443 anaesthetic): Toe phalanx: Distal refer Simple Fracture (reduction under general Assess, stabilise and 0445 anaesthetic): Toe phalanx: refer Compound Fracture (reduction under general Assess, stabilise and 0447 anaesthetic): Other: Simple refer Fracture (reduction under general Assess, stabilise and 0449 anaesthetic): Other: Compound refer Fracture (reduction under general Assess, stabilise and 0451 anaesthetic): Sternum and/or refer ribs: Closed Fracture (reduction under general Assess, stabilise and 0452 anaesthetic): Sternum and/or refer ribs: Open reduction and fixation of multiple fractured ribs for flail chest Fracture (reduction under general Assess, stabilise and 0455 anaesthetic): Spine: With or refer without paralysis: Cervical Fracture (reduction under general Assess, stabilise and 0456 anaesthetic): Spine: With or refer without paralysis: Rest

Page 73 of 109

Fracture (reduction under general Assess, stabilise and 0461 anaesthetic): Compression refer fracture: Cervical Fracture (reduction under general Assess, stabilise and 0462 anaesthetic): Compression refer fracture: Rest Fracture (reduction under general Assess, stabilise and 0463 anaesthetic): Spinous or refer transverse processes: Cervical Fracture (reduction under general Assess, stabilise and 0464 anaesthetic): Spinous or refer transverse processes: Rest Bones: Fractures (reduction Assess, stabilise and under general anaesthetic - refer refer to modifier 0047): Operations for fractures Fractures involving large joints Assess, stabilise and 0465 (includes the item for the relative refer bone) (this item may not be used as a modifier) Percutaneous insertion plus Assess, stabilise and 0473 subsequent removal of Kirschner refer wires or Steinmann pins (no after-care) (modifier 0005 not applicable) Acute or chronic osteomyelitis: In-patient 0509 Conservative treatment Joints: Dislocations Joint: Dislocation: Clavicle either Assess, stabilise and 0547 end refer Joint: Dislocation: Shoulder Assess, stabilise and 0549 refer Joint: Dislocation: Elbow Assess, stabilise and 0551 refer Joint: Dislocation: Wrist Assess, stabilise and 0552 refer Joint: Dislocation: Perilunar trans- Assess, stabilise and 0553 scaphoid fracture dislocation refer Joint: Dislocation: Lunate Assess, stabilise and 0555 refer Joint: Dislocation: Carpo- Assess, stabilise and 0556 metacarpo dislocation refer Joint: Dislocation: Metacarpo- Assess, stabilise and 0557 phalangeal or interphalangeal refer (hand) Joint: Dislocation: Hip Assess, stabilise and 0559 refer Joint: Dislocation: Knee Assess, stabilise and 0561 refer Joint: Dislocation: Patella Assess, stabilise and 0563 refer Joint: Dislocation: Ankle Assess, stabilise and 0565 refer

Page 74 of 109

Joint: Dislocation: Sub-Talar Assess, stabilise and 0567 dislocation refer Joint: Dislocation: Intertarsal or Assess, stabilise and 0569 Tarsometatarsal or Mid-tarsal refer Joint: Dislocation: Meta- Assess, stabilise and 0571 tarsophalangeal or refer interphalangeal joints (foot) Joints: Capsular operations Capsulotomy or arthrotomy or Drainage only 0582 biopsy or drainage of joint: Small joint (including three weeks after- care) Capsulotomy or arthrotomy or Drainage only 0583 biopsy or drainage of joint: Large joint (including three weeks after- care) Aspiration of joint or intra-articular Out-patient 0661 injection (not including after-care) (modifier 0005 not applicable) Multiple intra-articular injections Out-patient 0663 for rheumatoid arthritis (excluding after-care) (modifier 0005 not applicable): First joint Multiple intra-articular injections Out-patient 0665 for rheumatoid arthritis (excluding after-care) (modifier 0005 not applicable): Additional (each) Bursae and ganglia Excision: Semimembranosus In patient 0847 Excision: Prepatellar In patient 0849 Excision: Olecranon In patient 0851 Excision: Small bursa or ganglion In patient 0853 Excision: Compound palmar In patient 0855 ganglion or synovectomy Bursae and ganglia: Aspiration or 0857 injection (no after-care) (modifier 0005 not applicable) Musculo-skeletal system: Miscellaneous Subsequent plasters Out-patient 0869 Ponseti technique assistant In/out-patient 0874 (medical practitioner)

Removal of internal fixatives or In/Out-patient 0883 prosthesis: Readily accessible Plasters (exclusive of after-care) Spica, plaster jacket or hinged In/Out-patient 0889 cast brace (excluding after-care) Tumours: Epidermoid cysts In/Out-patient 0919 Tumours: Ganglion or fibroma In/Out-patient 0920

Page 75 of 109

Tumours: Nodular synovitis In/Out-patient 0921 (Giant cell tumour of tendon sheath) Removal of foreign bodies In/Out-patient 0922 requiring incision: Under local anaesthetic Removal of foreign bodies In/Out-patient 0923 requiring incision: Under general or regional anaesthetic Crushed hand injuries: Initial Assess, stabilise and 0924 extensive soft tissue toilet under refer general anaesthetic (sliding scale) - Minimum Crushed hand injuries: In/out hospital 0925 Subsequent dressing changes under general anaesthetic Amputations Amputations: Specific Assess, stabilise and 3.3.1 Amputations refer Amputation: Fore-quarter Assess, stabilise and 0682 amputation refer Amputation: Through shoulder Assess, stabilise and 0683 refer Amputation: Upper arm or fore- Assess, stabilise and 0685 arm refer Partial amputation of the hand: Assess, stabilise and 0687 One ray refer Amputation: Whole or part of Assess, stabilise and 0691 finger refer Hindquarter amputation Assess, stabilise and 0693 refer Amputation: Through hip joint Assess, stabilise and 0695 region refer Amputation: Through thigh Assess, stabilise and 0697 refer Amputation: Below knee, through Assess, stabilise and 0699 knee or Syme refer Amputation: Trans-metatarsal or Assess, stabilise and 0701 trans-tarsal refer Amputation: Foot: One ray Assess, stabilise and 0703 refer Amputation: Toe Assess, stabilise and 0705 refer Abdomen

Appendicectomy Assess, stabilise and 1675 refer Peritoneal lavage Assess, stabilise and 1800 refer Inguinal or femoral hernia: Adult Assess, stabilise and 1819 refer Umbilical hernia: Adult Assess, stabilise and 1831 refer

Page 76 of 109

Umbilical hernia: Child under 14 Assess, stabilise and 1833 years refer

10.3 Assistive Devices and consumables 58. Assistive devices and technologies’ primary purpose is to maintain or improve an individual’s functioning and independence to facilitate participation and enhance overall well-being. The following devices are proposed; • Mobility devices • Positioning devices • Prosthetics, orthotics and orthopaedic shoes • Daily living devices • Vision devices • Hearing devices

Table 13: Assistive Devices and Consumables Category ID Category Description

2000001 Active pressure relieving and accessories Based on clinical need

2000002 Air Cast Braces and Accessories 2000005 Apnoea mattress and monitor Based on clinical need 2000006 Arch Supports/ Foot orthotics

2000007 Arco-Pedico Shoes (Post-Bunionectomy) motivation required 2000008 Arm Immobiliser Sling For immobilisation based on clinical need e.g. fall injuries, twisted or swollen arm etc, 2000009 Back Brace and Accessories For immobilisation based on clinical need e.g. acute back pain, 2000010 Bath Raiser or Hoist– clinical motivation Based clinical need required 2000011 Bath Swivel Stool/ shower chair and accessories 2000012 Bedpans 2000014 Braces: Knee, ankle, wrist, arm and Entry level braces for immobilisation based accessories on condition. 2000017 Breast Pump Based on clinical need

2000084 Casting and Splinting 2000019 Catheters indwelling and intermittent male Some patients come for insertion and and female and Catheter bags changing of catheter...... catheter care. 2000020 Cervical Collar and accessories For immobilisation based on condition.

Page 77 of 109

2000023 Chronic tracheostomy tubes and Home or PHC facility care accessories 2000025 Stoma products/ accessories, including Home or PHC facility care colostomy,urostomy, ileostomy,gastrostomy and evacuation bags 2000026 Commode – clinical motivation required Home care accessory of personal nature/ could be re-usable but patients often buy for convenience. Or clinical need 2000086 Compression Garments For maintenance after diagnosis 2000029 Compression/ DVT support For maintenance after diagnosis

2000028 Crutches

Electro larynx and accessories including rechargeable batteries 2000030 Elastic Support Guards 2000101 Gait Training Mobility Aid and accessories 2000032 Glucometers and accessories 2000033 Grab rails / Handrails

2000035 Hand/Finger splint For immobilisation based on clinical needs 2000036 Hearing Aids-bilateral hearing aid every 36 months 2000038 Humidifier Based on clinical need,

2000039 Humidifiers (used with CPAP machine) Based on clinical need, 2000040 Incontinence /urinary Sheath Usually home care based on clinical need

2000041 Incontinent Pads / Adult Nappies- for Based on clinical need incontinence 2000042 Insoles – Simple On prescription, one pair per year

2000079 Insulin pens and syringes 2000043 Knee immobilizer – clinical motivation Based on clinical need required 2000046 Monkey Chain and Pole Based on clinical need 2000047 Moonboots/ Moonwalker/ Foamwalker On prescription

2000048 Nebuliser and accessories Based on clinical need 2000050 Orthopaedic Cushion (Obus seat) Based on clinical need 2000090 Oxygen and accessories i.e masks,nasal On prescription cannulas, reservoirs 2000091 Pain Control Devices and accessories Based on clinical need

2000051 Positioning system Based on clinical need

2000052 Prosthetics, Components and Accessories Based on clinical need

2000053 Raised Heel Insert Based on clinical need

Page 78 of 109

2000054 Rocker Sole Based on clinical need 2000074 Special Chairs and Accessories Based on clinical need

2000015 Special Cushions and Accessories Based on clinical need 2000096 Speech aid device

2000060 Splints Based on clinical need

2000061 Standing Frame Based on clinical need

2000064 Support Belts - post operatively Based on clinical need 2000065 Surgical (TED) Stockings Based on clinical need 2000067 Toilet raiser Based on clinical need

2000069 Transfer Boards for disabled

2000071 Walking Frame / Aids and accessories

2000073 Wheelchair and accessories where required 2000094 Wheelchair Accessories 2000075/6 Wheelchair Cushion Disposable Device with -125mmHg pressure mechanical non- Dressing (Small, Medium, Large) powered NPWT Device with dressing kit

Basic Dressings Crepe Bandages Adhesive band Sec protective band Soft woven gauze Gauze dressings Primary Contact Impregnated Tulle Layer/Non- Silicone based Adherent Hydrocolloid/Paraffin/Petrolateum Polymeric membrane Specialised for fingers Specialised for Toes

Malodour control Activated Charcoal with/out Silver

Debriding agents Autolytic Enzymatic Polymetric membrane 2nd Generation hydrogel sheet Osmolytic debriding agents

Moisture control Foam dressings Hydrocolloid Super Absorbent dressings

Page 79 of 109

Antimicrobials Topical PVP-1 dressings Silver Alginate based antibacterials Oxysalts Silver Metalic Silver Cytoflamm gel Antimicrobial Gauze dressings Chlorhexidine dressings Silver Gel

Topical Solutions Iodine- based Povidone Iodine Chlorhexidine-based solution Normal saline Sterile water Bio scrub Ringers lactate Irrigation fluid

Surrounding skin Barrier cream protectors Barrier Films

11. Rehabilitation

59. WHO defines rehabilitation as “a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments(38)". Rehabilitation is aimed at; • prevention of the loss of function • slowing the rate of loss of function • improvement or restoration of function • compensation for lost function, maintenance of current function. 60. Rehabilitation may be needed by an individual who experiences difficulties in mobility, vision, hearing, speech, swallowing, or cognition. Interventions may include services provided by rehabilitation professionals such as physiotherapists, occupational therapists, speech and language therapists, orthotic and prosthetic technicians, psychologists, physical and rehabilitation medicine doctors. 61. The Policy Framework and Strategy for Disability and Rehabilitation services in South Africa outlines comprehensive and integrated disability and rehabilitation services within the broader health and developmental context to facilitate improved access at all levels of health care(39). The purpose of rehabilitation is to restore and compensate for the loss of functioning and preventing or slowing deterioration

Page 80 of 109

in functioning in every area of a person’s life. The different interventions include training, exercises, and compensatory strategies, education, support and counselling. Table 14 proposes a list of rehabilitation services by different age groups.

Table 14: Rehabilitation Services

Category Interventions and Description Service Code Services Team Services Pre-and Post-natal Individualised Treatment and rehabilitation for 108; 109; 201; 203; 4Therapist (OT, treatment and pregnant women with pathology 205; 207; 209; 211; PT, SLT, BK, rehabilitation for e.g. chest infection, mental 301; 303; 305; 307; Psychologist, SW, pregnant women with health problems, CVA, 308; 309; 311; 313; DT, Audiologist) pathology cognitive/emotional impairment, 315; 317; 319; 401; Integration within teenage pregnancies, mothers 431 existing with risk factors such as low programmes, CD4/High VL, pre-eclampsia, services, 701, 702 & 703 maternal syphilis or similar guidelines and (evaluation); 901 or protocols 903 (visiting)

300; 301; 318; 319; 704 (chest) 305; 307;308; 313; 501; 502 503; 505; 507 509 (excl./rehab) 506; 001;302; 303; 310;304 328; 401; 405 (stress) 708 (advice & education)

937 or 938 940; 941 939

901, 903, 908, 909, 912, 923, 926, 927, 928, 929, 931, 925, 913, 914, 915, 916, 917, 918, 920, 922, 930, 933, 934, 936

68301 68302 68303 68304 68040 68010 68011 68012 68013 68043 68056 68207 68209 68061 68063 68055 68060 68065 68065 68051 68057 68054 68053 68215 68217 68219 68048

4 OT: Occupational therapy, PT: Physiotherapy, SW: Social worker, DT: Dieticians, BK: Biokineticist; MLRW: Mid-level rehabilitation worker, SLT: speech and language therapist

Page 81 of 109

68205 68041 68201 68042 68014 68015 68016 68017 68203

Post-delivery Post-delivery treatment for 108; 109; 201; 203 Therapist (OT, treatment for women women with pathology or 205; 207; 209; 211; PT, SLT, DT, with pathology functional impairments (e.g. 213; 217; 219; 221; psychologist, SW, mobilisation with difficulty) or 223; 225; 301; 303; audiologist) special support needs (e.g. 305; 307; 308; 309; MHCU) 311; 313; 315; 317; 319; 401; 403; 405; 407; 409; 411; 413; 415; 417; 419; 421 423; 425; 427; 431 1001; 1002; 1003 1008; 1004; 1005 1006; 1007; 701; 702; 703; 704; 705; 706; 707; 708; 709 710; 711; 712; 713 714; 715; 716; 717 718; 719; 720; 721 801; 802; 803; 804; 805; 806; 807; 808; 809; 810; 811; 812 813; 814; 815; 816 817; 818; 901; 902 903; 905; 905; 906 0021 006; 103; 203; 302 300; 301; 318; 319; 704 (chest) 305; 307;308; 313; 501; 502 503; 505; 507 509 (excl./rehab)

68301 68302 68303 68304 68009 68040 68010 68011 68012 68013 68043 68056 68207 68209 68061 68065 68063 68055 68060 68065 68051 68057 68054 68021 68022 68023 68024 68053 68215 68217 68219 68048 68213 68205 68201 68042 68041 Post-natal exercises Group or individual exercises and 308; 313;501;505 PT and BK, healthy lifestyle advice 509;708 Integration within 901, 903, 908, 909, existing 912, 923, 926, 927, programmes, 928, 929, 931, 925, services, 913, 914, 915, 916, guidelines and 917, 918, 920, 922, protocols 930, 933, 934, 936

Page 82 of 109

Post-natal nutritional Group or individual sessions for DT counselling specific pathologies where clinically indicated as well as healthy lifestyle advice Neonatal: 0-28 days Rehabilitation All neonates with established 108; 109; 201; 203 Therapist (in intervention for problems e.g. feeding difficulties, 207; 209; 211; 213 collaboration with neonates with clubfoot and other positional 217; 219; 221; 223 Medical Officer, established problems deformities e.g. spinal bifida etc. 225; 309; 311; 401 Dietician, SW, and sensory problems (e.g. 403; 405; 407; 415; optometrist and ROPs, hearing loss, visual 419; 425; 427; 431 Psychologist, as impairment) 701; 703; 707; 710; well as referrals to 715; 716; 718; 720 podiatry) 721; 722; 0021 300; 301; 302; 303 315; 305; 319; 318 323; 405; 407; 501 509; 708

68303 68302 68304 68303 68043 68215 68041 68217 68219 68205

Infant and children (29 days – 5 years) Rehabilitation All children with developmental 108; 109; 110; 111 Collaborative (Individual and/or delay or established disability 201; 203; 205; 207; multidisciplinary group therapy 209; 211; 213; 217; team (PT, OT, 219; 221; 223; 225 SLT, Audiology, 301; 303; 305; 307 SW, Psychologist, 309; 311; 313; 315 MO, DT and 401; 403; 405; 407 MLRW. Podiatry 409; 411; 413; 415 and MOPS where 417; 419; 421; 423 indicated) 425; 427; 431; 434 501; 0008; 1001; 1002; 1003; 1008 0009; 701; 702; 703; 704; 705; 706 707; 708; 709; 710 711; 712; 713; 714 715; 716; 717; 718 719; 720; 721; 801 802; 803; 804; 805 806; 807; 808; 809 810; 811; 812; 813 814; 815; 816; 817 818; 901; 902; 903 905; 906; 0021 305; 307; 308; 501 502; 503; 505; 507 509 (exc./rehab)

901, 903, 908, 909, 912, 923, 926, 927, 928, 929, 931, 925, 913, 914, 915, 916, 917, 918, 920, 922, 930, 933, 934, 936

Page 83 of 109

68301 68302 68303 68304 68040 68010 68011 68012 68013 68043 68056 68207 68209 68061 68063 68055 68060 68065 68065 68051 68057 68054 68053 68215 68217 68219 68048 68205 68041 68201 68042 68009 68021 68022 68023 68024 68048 68203 Assessment and All children with general 108; 109; 431 OT, PT, SLT, intervention childhood conditions that would 901, 903, 908, 909 Audio and rehab Education, respond well to specific counselling and physio/OT/SLT/audio (and others technicians home programme for such as dental, dietician, eye Assessment/ Other members of caregivers health, etc.) intervention as Counselling the MDT including supported by profession-specific 701; 702; 703 optometry, clinical guidelines, scope of dietetics, social practice, referral guidelines 901, 909, 908, 913, work, psychology, 914, 915, 916, 917, podiatry, MOPS, 920, 922, 933, 936 MO. Integration within EXC / rehab existing 305; 307; 501; 502 programmes, 507; 509 services, 912, 923, 926, 927, guidelines and 928, 929, 931, 930, protocols 934

Education 708 922

68303 68304 68302 68301 68012 68043 68056 68065 68061 68207 68209 68054 68053 68051 68057 68205

Education, All children with general 108; 109; 427; 431 OT, PT, SLT, BK, counselling and childhood conditions such as Audio and rehab home programme for orthopaedics/trauma, chest, 901, 909, 908, 913, specific caregivers malnutrition, developmental 914, 915, 916, 917, technicians delays, burns, neuro and other 920 Orthotist, Prosthetist

Page 84 of 109

medical and surgical conditions Counselling Podiatrist and foot deformities 701; 702; 703 Optometrist, 922, 933, 936 social worker, dietician, dental) Education Integration within 708 existing 922 programmes, services, EXC / rehab guidelines and 305; 307; 501; 502 protocols and 507; 509 scope of practise

912, 923, 926, 927, 928, 929, 931, 930, 934

68301 68302 68303 68304 68009 68040 68010 68011 68012 68013 68043 68056 68207 68209 68061 68065 68063 68055 68060 68065 68051 68057 68054 68021 68022 68023 68024 68053 68215 68217 68219 68048 68213 68205 68201 68042 68041 68205 68009 68215 68048 Assessment, Children requiring seating/ 108; 109; 201; 203 Therapist trained measurement, fitting positioning interventions, and 205; 207; 309; 311 in Basic/ and training for those with interventions requiring 313; 315; 317; 319 intermediate/ children (and their reassessment/adaptation/ repairs 401; 403; 405; 407 advanced seating caregivers) 409; 411; 413; 415 (PT/ OT/BK) 417; 0021 701; 702; 703; 305 501; 509; 708

901, 903, 908, 909, 912, 923, 926, 927, 928, 929, 931, 925, 913, 914, 915, 916, 917, 918, 920, 922, 930, 933, 934, 936

68301 68302 68303 68304 68012 68041 68043 68056 68207 68209 68054 68051 68057 68205 68055 68060 68067 Wheelchair repair Provide wheelchair repair and 108; 109; 201; 207 Wheelchair repair and reseating reseating services and re-seating 209; 309; 311; 313 technician or services services for children using 315; 401; 403; 405 MLRW wheelchairs, buggies, 407; 409; 411; 413 positioners, etc 415; 417; 0021

Page 85 of 109

701; 702; 703; 305 501; 509; 708 (reseating)

Children 6-17 years Rehabilitation and Children 6-17 years old with 108; 109; 110; 111 OT, PT, SLT, BK, interventions for acute, sub-acute or chronic 201; 203; 205; 207; DT, Audio, conditions that would conditions that require in-patient 209; 211; 213; 217; MOPS, podiatry necessitate rehab or out-patient rehabilitation 219; 221; 223; 225 and the various services 301; 303; 305; 307 profession- 309; 311; 313; 315 specific rehab 401; 403; 405; 407 technicians 409; 411; 413; 415 Orthotist and 417; 419; 421; 423 prosthetist and 425; 427; 431; 434 technician 501; 0008; 1001; 1002; 1003; 1008 0009; 701; 702; 703; 704; 705; 706 707; 708; 709; 710 711; 712; 713; 714 715; 716; 717; 718 719; 720; 721; 801 802; 803; 804; 805 806; 807; 808; 809 810; 811; 812; 813 814; 815; 816; 817 818; 901; 902; 903 905; 906; 0021

68301 68302 68303 68304 68009 68040 68010 68011 68012 68013 68043 68056 68207 68209 68061 68065 68063 68055 68060 68065 68051 68057 68054 68021 68022 68023 68024 68053 68215 68217 68219 68048 68213 68205 68201 68042 68041 68205 68009 68215 68048 68053 68215 68217 68219 68048 68213 68205 68201 68042 68041 68205 68009 68215 68048 All PT and BK

Assessment, Children requiring seating/ 108; 109; 201; 203 Therapist trained measurement, fitting positioning interventions, and 205; 207; 309; 311 in Basic/ and training for those with interventions requiring 313; 315; 317; 319 intermediate/ children (and their reassessment/adaptation/ repairs 401; 403; 405; 407 advanced seating caregivers) 409; 411; 413; 415 (BK/PT/ OT) 417; 0021

Page 86 of 109

701; 702; 703; 305 501; 509; 708

901, 903, 909, 908913, 915, 916, 920

68301 68302 68303 68304 68012 68041 68043 68056 68207 68209 68054 68051 68057 68205 68055 68060 68067 Wheelchair repair Provide wheelchair repair and 108; 109; 201; 207 Wheelchair repair and reseating reseating services and re-seating 209; 309; 311; 313 technician or services and re- services for children using 315; 401; 403; 405 MLRW seating services wheelchairs, buggies, 407; 409; 411; 413 positioners, etc 415; 417; 0021

701; 702; 703; 305 501; 509; 708 (reseating) Individual and group Persons at risk of developing 108; 109; 110; 111 Social worker, interventions for mental health issues, and MHCU 201; 203; 205; 207 MHC nurse, children with mental themselves: children and their 209; 211; 301; 303 psychologist, health conditions caregivers 305; 307; 308; 309 doctor, OT, OTT, including intellectual 311; 313; 315; 317 DT. Impairment. 319; 401; 0021

305; 307; 308; 501 502; 505; 507; 509 (EXC / rehab) 506; 103; 302; 303 310; 401; 405 (Stress) 708 (Advice & education)

68301 68302 68303 68304 68009 68040 68010 68011 68012 68013 68043 68056 68207 68209 68061 68065 68063 68055 68060 68065 68051 68057 68054 68021 68022 68023 68024 68053 68215 68217 68219 68048 68213 68205 68201 68042 68041 68205 68009 68215 68048 Adults 18 and above Assessment and Adults with minor to major 108; 109; 110; 111 BK, OT, PT, SLT, intervention for those impairments and resultant 201; 203; 205; 207; DT, Audio, adults with temporary or permanent 209; 211; 213; 217; profession- disability, including those at risk 219; 221; 223; 225 specific

Page 87 of 109

temporary/minor of disability that can be 301; 303; 305; 307 technicians, impairments successfully addressed (in part 309; 311; 313; 315 CCGs and or in full, using education, advice, 401; 403; 405; 407 CBRWs adaptive strategies, hands-on 409; 411; 413; 415 techniques and home 417; 419; 421; 423 Orthotist and management programmes) 425; 427; 431; 434 prosthetist and 501; 0008; 1001; technician, 1002; 1003; 1008 podiatrist 0009; 701; 702; 703; 704; 705; 706 707; 708; 709; 710 711; 712; 713; 714 715; 716; 717; 718 719; 720; 721; 801 802; 803; 804; 805 806; 807; 808; 809 810; 811; 812; 813 814; 815; 816; 817 818; 901; 902; 903 905; 906

68301 68302 68303 68304 68009 68040

68010 68011 68012 68013 68043 68056 68207 68209 68061 68065 68063 68055 68060 68065 68051 68057 68054 68021 68022 68023 68024 68053 68215 68217 68219 68048 68213 68205 68201 68042 68041 68205 68009 68215 68048 BK and PT codes

Assessment, Adults requiring seating/ 108; 109; 201; 203 Therapist trained measurement, fitting positioning interventions, and 205; 207; 309; 311 in Basic/ and training for those with interventions requiring 313; 315; 317; 319 intermediate/ adults (and their reassessment/adaptation/ repairs 401; 403; 405; 407 advanced seating caregivers) 409; 411; 413; 415 (PT/ OT) 417; 0021

701; 702; 703; 305 501; 509; 708

901, 903, 909, 908, 913, 914, 915, 916, 917, 920 68301 68302 68303 68304 68012 68041 68043 68056 68207 68209 68054 68051 68057 68205 68055 68060 68067

Page 88 of 109

Wheelchair repair Provide wheelchair repair and 108; 109; 201; 207 Wheelchair repair and reseating reseating services and re-seating 209; 309; 311; 313 technician or services services for children using 315; 401; 403; 405 MLRW wheelchairs, buggies, 407; 409; 411; 413 positioners, etc 415; 417; 0021

701; 702; 703; 305 501; 509; 708 (reseating)

Vocational Comprehensive individual and 108; 109; 107; 110 Occupational Rehabilitation group OT programs for all those 111; 201; 203; 205 therapists currently recovering, or having 207; 209; 211; 301 recovered with residual 303; 305; 307; 308 impairment, who are of working 309; 311; 313; 315; age and wish to return to work 317; 319; 401; 501 503 Rehabilitation Assess, measure, prescribe and All OT Codes Therapists issue appropriate assistive Wheelchair repair device, and train in using it 701; 702; 703 technicians 305; 501; 509; 708

Individual and group Persons at risk of developing 108; 109; 110; 111 Social worker, interventions for mental health issues 201; 203; 205; 207 MHC nurse, people with mental 209; 211; 301; 303 psychologist, health conditions 305; 307; 308; 309 doctor, OT, OTT, including Intellectual 311; 313; 315; 317 DT. Impairment. 319; 401; 0021

68301 68302 68303 68304 68012 68041 68043 68056 68207 68209 68054 68051 68057 68205 68055 68060 68067 Assess, measure, Geriatrics requiring/using various 108; 109; 110; 111 prescribe and issue assistive devices 201; 203; 205; 207; appropriate assistive 209; 211; 213; 217; device, and train in 219; 221; 223; 225 using it 301; 303; 305; 307 309; 311; 313; 315 401; 403; 405; 407 409; 411; 413; 415 417; 419; 421; 423 425; 427; 431; 434 501; 0008; 1001; 1002; 1003; 1008 0009; 701; 702; 703; 704; 705; 706 707; 708; 709; 710 711; 712; 713; 714 715; 716; 717; 718 719; 720; 721; 801 802; 803; 804; 805 806; 807; 808; 809 810; 811; 812; 813 814; 815; 816; 817 818; 901; 902; 903 905; 906

Page 89 of 109

701; 702; 703; 305 501; 509; 708

Rehabilitation Geriatrics with minor to major All PT, BK and OT OT, PT, SLT, BK, intervention impairments and resultant codes DT, Audio, temporary or permanent profession- disability, including those at risk specific of disability technicians, CCGs and CBRWs Orthotist, prosthetist and technician

Day Care Services for patients In -facility outpatient services All PT, BK and OT Multi-professional who require should be available to prevent codes team as required assistance but not unnecessary admissions and hospitalisation avert costs that come with should be rendered hospitalisation at appropriate facilities or institutions

12. Palliative Care

62. WHO defines palliative care as an approach that aims to improve the quality of life of patients and families facing problems associated with life-threatening illness, through the prevention and relief of suffering by early identification and impeccable assessment, and treatment of pain and other problems including physical, psychosocial and spiritual. According to WHO, palliative care: - provides relief from pain and other distressing symptoms; - affirms life and regards dying as a normal process; - intends neither to hasten nor postpone death; - integrates the psychological and spiritual aspects of patient care; - offers a support system to help patients live as actively as possible until death; - offers a support system to help the family cope during the patient’s illness, and in their own bereavement; - will enhance quality of life, and may also positively influence the course of illness; - is applicable early during illness, in conjunction with other therapies that are intended to prolong - life, such as chemotherapy or radiation therapy, and - includes those investigations needed to better understand and manage distressing clinical complications; - uses a team approach to address the needs of patients and their families, including bereavement counselling, if indicated(40).

Page 90 of 109

63. The national policy on palliative care identifies the following multi-disciplinary team to provide palliative care at the district level: • Professional Nurse with necessary palliative care training. • Doctor with the necessary palliative care training. • Social worker with the necessary palliative care training. • Allied Health Professionals with the necessary palliative care training. 64. Services available in the package should be available for palliative care. Special emphasis is made on the following: (i) Palliative care assessment – holistic needs-based assessment of patient and family: • First visit is long and complex, and typically takes 2 to 2.5 hours or even longer. • This visit typically includes all of the following: taking a comprehensive history of current and previous diagnoses, treatments and medications; drawing a genogram; a holistic needs and symptom assessment (physical, psychological, social and spiritual); assessment of mental state using a standardised test such as the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MOCA) physical examination; explaining investigation results and treatment options, including potential risks and benefits; counselling and explaining end-of-life care; discussion with family members (more than just giving information and often involves mediating where there is conflict or differences of opinion); arranging care and equipment; explaining medication and time schedules; completion of forms; sharing information with Multi- Disciplinary Teams (MDT) or Interdisciplinary team (IDT) members. • It is proposed that the following codes be claimed for this initial complex and lengthy assessment: 0192 + 0145 + 0129 x up to 4 (depending on length beyond 60 minutes). (ii) Advanced care planning: • Visit typically 2 to 2.5 hours or even longer. This visit includes elements of the first assessment visit, as well as further discussions around goals of care, planning of future care, preferences around end-of-life issues, preferences regarding hospitalization and resuscitation etc., Living Will, nomination of a medical proxy, counselling and repeated explanations surrounding medication and care. • It is proposed that codes similar to the first assessment visit be claimed, depending on length of consult, i.e. 0192 + 0145 + 0129 x up to 4 (depending on length beyond 60 minutes). (iii) Follow-up visits; holistic needs-based palliative care management: • By various members of the MDT/IDT depending on patient/family need.

Page 91 of 109

• At times more than one member of the MDT/IDT is present at the same patient visit; each should claim separately for their visit. • It is proposed that doctors claim for visits and procedures utilising current available codes where these exist (see table below). The home-based codes (0145, 0147) should be reimbursed where applicable. • For visits longer than 60 minutes, 0129 x up to 4 should be reimbursed, depending on length of visit beyond 60 minutes. • Doctors should also be able to claim for telephonic and electronic consultations, as well as reports and additional scripts etc. • Palliative services are integrated in the rest of the package. (iv) Care co-ordination and communication: • Each patient/family requires care co-ordination for palliative care to be efficient, effective and potentially cost-saving. Communication between members of a team, including patient and family, is an often under-estimated and under-valued aspect of a good and comprehensive palliative care service. • The palliative care provider performs the care co-ordination; and includes correspondence and collaboration with patients, family members, funders, colleagues and members of the MDT/IDT. (v) Counselling: • Family meetings and individual counselling sessions are an essential palliative care service for patient and family members. This includes counselling of family members in the bereavement phase. (vi) End-of-life care: • Patients nearing/at end-of-life and their families require more intensive palliative care support and more frequent visits. • Propose that, where necessary, end-of-life benefits could be extended beyond 14 days with additional motivation. • The following may be required during the end-of-life period: o Daily visits by a member of the MDT o More intensive/frequent family meetings and counselling sessions o Potential use of a syringe driver o Access to 24-hour care (vii) Intensive palliative care for patients not yet at end-of-life:

Page 92 of 109

• It must be noted that the above increased needs may also be required by a palliative care patient before the defined end-of-life period e.g. in the case of a patient with bowel obstruction cared for at home or in a hospice setting, or a patient with severe and distressing pain or other symptoms such as nausea and vomiting, or a palliative care emergency situation such as spinal cord compression. • In these instances, the following should be available to such patients upon special motivation: o Daily visits by a member of the MDT o More intensive/frequent family meetings and counselling sessions o Potential use of a syringe driver • Access to 24-hour care

(viii) Hospice care • For terminally ill patients (960)

13. Way Forward 65. The proposed set of services and interventions are a first step towards defining services that should be available in a primary health care setting. The next step will be to cost and prioritise the services according to the principles in annexure A.

Page 93 of 109

14. References 1. StatsSA. Mortality and causes of death in South Africa, 2016: Findings from death notification [Internet]. Pretoria; 2018. Available from: http://www.statssa.gov.za/publications/P03093/P030932016.pdf 2. Statistics South Africa. Mid-year population estimates [Internet]. Pretoria; 2018. Available from: https://www.statssa.gov.za/publications/P0302/P03022018.pdf 3. World Health Organization. Noncommunicable Diseases Country Profiles. 2018. 4. Council for Medical Schemes. Annual Report. Pretoria; 5. National Department of Health. National Mental Health Policy Framework and Strategic Plan 2013-2020. Pretoria; 2012. 6. Jacob N, Coetzee D. Mental illness in the Western Cape Province, South Africa: A review of the burden of disease and healthcare interventions. South African Med J. 2018;108(3):176–80. 7. Lund C, Myer L, Stein DJ, Williams DR, Flisher AJ. Mental illness and lost income among adult South Africans. Soc Psychiatry Psychiatr Epidemiol. 2013;48(5):845–51. 8. WHO-UNICEF. Alma Ata Declaration on Primary Health Care. 1978. 9. National Department of Health. Guidelines for Maternity Care in South Africa: A manual for clinics, community health centres and distrcit hospitals. Pretoria; 2016. 10. Kramer MS, McDonald SW. Aerobic exercise for women during pregnancy. Cochrane Database Syst Rev. 2009;(4). 11. Meher S, Duley L. Exercise or other physical activity for preventing pre-eclampsia and its complications. Cochrane Database Syst Rev. 2006; 12. Han S, Middleton P, Crowther CA. Exercise for pregnant women for preventing gestational diabetes mellitus. Cochrane Database Syst Rev. 2012; 13. Woodley SJ, Boyle R, Cody JD, Mørkved S, Hay-Smith EJC. Pelvic floor muscle training for prevention and treatment of urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database Syst Rev. 2017;2017(12). 14. Professional Board for Speech L and HP. Early Hearing Detection and Intervention. 2018. 15. National Department of Health, National Department of Basic Education. Integrated School Health Policy. 2012. 16. SEMDSA Type 2 Diabetes Guidelines Expert Committee. SEMDSA 2017 Guidelines for the Management of Type 2 diabetes mellitus. J Endocrinol Metab Diabetes South Africa. 2017;22(1). 17. National Department of Health. Breast Cancer Control Policy. Pretoria; 2017. 18. U.S. Preventive Services Task Force. Breast Cancer: Screening [Internet]. 2009 [cited 2019 Nov 27]. Available from: https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast- cancer-screening 19. National Department of Health. Cervical Cancer Prevention and Control Policy [Internet]. 2017. Available from: file://cmsnas02/Users/thsehlae/Downloads/cervical cancer policy (6).pdf

Page 94 of 109

20. American Cancer Society. Recommendations for colorecatal cancer early detection. [Internet]. Available from: https://www.cancer.org/content/cancer/en/cancer/colon-rectal-cancer/detection- diagnosis-staging/acs-recommendations.html 21. Hewitson P, Glasziou P, Irwig L, Towler B, Watson E. Screening for colorectal cancer using the faecal occult blood test, Hemoccult. Cochrane Database Syst Rev. 2007;(1). 22. Holme O, Bretthauer M, Fretheim A, Odgaard-Jensen J, Hoff G. Flexible sigmoidoscopy versus faecal occult blood testing for colorectal cancer screening in asymptomatic individuals. Cochrane Database Syst Rev. 2013;2013(9). 23. Manser R, Lethaby A, Irving LB, Stone C, Byrnes G, Abramson MJ, et al. Screening for lung cancer. Cochrane Database Syst Rev. 2013;2013(6). 24. Taylor F, Huffman MD, Macedo AF, Moore THM, Burke M, Davey Smith G, et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. 2013;2017(5). 25. Mills EJ, Rachlis B, Wu P, Devereaux PJ, Arora P, Perri D. Primary Prevention of Cardiovascular Mortality and Events With Statin Treatments. A Network Meta-Analysis Involving More Than 65,000 Patients. J Am Coll Cardiol. 2008;52(22):1769–81. 26. Bischoff-Ferrari HA, Dawson-Hughes B, Willett WC, Staehelin HB, Bazemore MG, Zee RY, et al. Effect of Vitamin D on Falls: A Meta-analysis. J Am Med Assoc. 2004;291(16):1999–2006. 27. Pfeifer M, Begerow B, Minne HW, Suppan K, Fahrleitner-Pammer A, Dobnig H. Effects of a long-term vitamin D and calcium supplementation on falls and parameters of muscle function in community-dwelling older individuals. Osteoporos Int. 2009;20(2):315–22. 28. Lee SH, Kim HS. Exercise Interventions for Preventing Falls Among Older People in Care Facilities: A Meta-Analysis. Worldviews Evidence-Based Nurs [Internet]. 2017 Feb;14(1):74–80. Available from: http://doi.wiley.com/10.1111/wvn.12193 29. Irving GJ, Holden J, Yang R, Pope D. Hepatitis A immunisation in persons not previously exposed to hepatitis A. Cochrane Database Syst Rev. 2012; 30. Jefferson T, Demicheli V, Deeks J, MacMillan A, Sassi F, Pratt M. Vaccines for preventing hepatitis B in health care workers. Nurs Times. 2001;97(46):39. 31. Moberley S, Holden J, Tatham DP, Andrews RM. Vaccines for preventing pneumococcal infection in adults. Cochrane Database Syst Rev. 2013;2013(1). 32. Gagliardi AM, Andriolo BN, Torloni MR, Soares BG, de Oliveira Gomes J, Andriolo RB, et al. Vaccines for preventing herpes zoster in older adults. Cochrane database Syst Rev. 2019;2019(11). 33. U.S. Preventative Services Task Force. Screening for Chlamydia and Gonorrhea: Recommendation Statement. Am Fam Physician. 2015;91(7). 34. National Department of Health. South African Guidelines for The Prevention of Malaria. 2017. 35. National Department of Health. Standard Treatment Guidelines and Essential Medicines List for South Africa. Pretoria; 2018. 36. Petersen PE. The World Health Report 2003: Continous improvement of oral health in the 21st century-approach of the WHO Global Health Programme [Internet]. 2003. Available from: https://www.who.int/oral_health/media/en/orh_report03_en.pdf

Page 95 of 109

37. Glick M, Williams DM, Kleinman D V., Vujicic M, Watt RG, Weyant RJ. A new definition for oral health developed by the FDI World Dental Federation opens the door to a universal definition of oral health. J Am Dent Assoc. 2016;147(12):915–7. 38. World Health Organization, The World Bank. World Report on Disability. 2011. 39. National Department of Health. Framework and Strategy for Disability and Rehabilitation Services in South Africa 2015-2020. 2015. 40. World Health Organization. WHO Definition of Palliative Care [Internet]. p. 1. Available from: https://www.who.int/cancer/palliative/definition/en/

Page 96 of 109

ANNEXURE A: PRINCIPLES AND METHODS FOR PRIORITY SETTING TO GUIDE THE PMB REVIEW PROCESS

1. Background

This section of the report is provided in the context of the prescribed minimum benefits (PMB) review process, and provides the recommendations of the Priority Setting Committee, which was constituted with the following mandate:

• To define the principles that would underpin priority setting in the PMB review process. • To recommend the appropriate method/s for priority setting that will be used to determine the services to be included in the revised PMB package.

In its first deliberations, the Committee set about defining the priority setting process in order to gain a common understanding of the scope of work. Priority setting was understood to be a process of rationing or resource allocation, a multifaceted and complex problem faced by decision makers in the health system (1). From the outset, it was understood that priority setting was a complicated process that needed to be guided by a set of principles that were agreeable to multiple stakeholders. Resource allocation is value based and there is not one way of defining a successful priority setting process, with different disciplines offering different solutions on how priority setting can be done: health economics for example, focuses on efficiency, while policy approaches focus on legitimacy and evidence-based medicine primarily focuses on effectiveness (2). As such, it was important to firstly agree on a definition of priority setting and then set common values and principles that would guide the process.

PMBs are aimed at providing medical scheme members with continuous care to ensure health and wellbeing and to promote access to quality healthcare services. The selection of an essential package of services should thus be based on rational principles that ensure an equitable distribution of resources. However, balancing the gap between resources and opportunities in healthcare is a difficult process, and if not handled carefully, resource allocation can have a detrimental effect on both providers and consumers. While the PMB review is timely and necessary, this must follow proper processes and procedures that ultimately result in a PMB package that is both acceptable and fair. It is thus hoped that embarking on a priority setting process that is accompanied by acceptable values and norms will ensure delivery of a package that benefits all stakeholders (1).

2. The Principles for Priority Setting Recommended by the Committee

The Committee consulted widely and reviewed relevant literature to assess the common principles of priority setting adopted globally. The principles evaluated are given in Annexure A, showing how they have are applied in various settings, and from these, the following five core principles were adopted by the Committee:

1. Health Needs 2. Right to access health care services 3. Financial Risk Protection 4. Sustainability and Affordability 5. Clinical and Cost Effectiveness; Efficiency

1) Health Needs

Burden of disease is the total and cumulative health, social or economic impact of a disease or range of diseases in a population.

Page 97 of 109

Some of the challenges with this measure were identified as;

• Disproportionate spend on some diseases (communicable vs non-communicable) • Disease focus largely driven by international priorities • Data challenges and measurement issues

2) Right to access health care services

The timely use of health services to achieve the best health outcomes. Access relates to the opportunity to obtain and appropriately use quality health services. There are three dimensions to define access to healthcare:

1. Availability of health services (or physical access: whether appropriate services are available at the right place and time to meet population needs. 2. Affordability of services (financial access): ability to pay in the context of the household budget. Whether health services can be purchased without unreasonable sacrifices. 3. Acceptability of health services (cultural access: fit between provider and patient attitudes towards and expectations of each other.

The main challenge was identified as the definition itself. A robust definition of access is needed that is acceptable to both patients and providers and all stakeholders. This may be difficult to do as perceptions on access may differ. Data to measure the various indicators of access may also not be readily available to inform a priority setting process.

3) Financial Risk Protection

This can be defined as the protection against the financial uncertainty associated with the need to use health services and pay for them. Those in need should have access to all needed quality health services without financial hardship. Some indicators of financial risk protection include:

1. Incidence of catastrophic expenditure – proportion of households in a population who face catastrophic health expenditure. 2. Mean positive catastrophic overshoot – percentage points by which household spending on health exceeds the threshold of catastrophic expenditure. 3. Incidence of impoverishment – percentage of households in a population who fall into poverty due to health spending.

The main challenge with these concepts of financial risk protection is that an issue such as catastrophic expenditure, is difficult to measure, often requiring huge investments in population-based surveys to identify at risk households.

4) Affordability and Sustainability

Affordability is a measure of ability to purchase a good or a service, and describes whether a person or organization, with limited resources, is able to make a purchase without unacceptable or unreasonable sacrifices.

Sustainability is the long-term ability to mobilize and allocate sufficient resources for activities that meet individual or population health needs.

Page 98 of 109

5) Clinical and Cost-Effectiveness

Adopted interventions must be clinically effective and also provide value for money. The implication is that selected interventions must maximise total health benefits subject to budget constraints.

6) Efficiency

Efficiency measures whether healthcare resources are being used to get the best value for money. Technical efficiency refers to the relation between resources used and health outcomes.

3. Main approaches to priority setting reviewed by the Committee

Literature review was undertaken to identify methods for priority setting in health. Firstly, specific searches were made for literature focusing on health priority setting approaches, and from these the necessary papers were identified and reviewed. Secondly, ad hoc online searches were undertaken to identify more publications. Lastly, targeted searches were conducted in PubMed for appropriate studies that could be reviewed.

From the literature, six main approaches to priority setting were compiled and reviewed by the Committee:

• Multi-Criteria Decision Analysis (MCDA) • Program Budgeting and Marginal Analysis (PBMA) • Accountability for Reasonableness (AFR) • QALY/DALY league tables • Target setting • Core services

a) Multi-Criteria Decision Analysis

Multi-Criteria Decision Analysis (MCDA) is a general framework for supporting complex decision-making situations with multiple and often conflicting objectives that stakeholders groups and/or decision-makers value differently. It is defined as “a set of methods and approaches to aid decision making, where decisions are based on more than one criterion, which make explicit the impact of all the criteria applied and the relative importance attached to them”. MCDA is a valuable tool that we can apply to many complex decision-making situations. It is most applicable to solving problems that are characterized as a choice among alternatives. An overview of the main steps involved in conducting an MCDA is provided below:

1. Defining the decision problem: identifying objectives, type of decision, alternatives, stakeholders and output required. 2. Selecting and structuring criteria: identifying criteria relevant for evaluating alternatives. 3. Measuring performance: gathering data about the alternatives’ performance on the criteria and summarize this in a “performance matrix”. 4. Scoring alternatives: eliciting stakeholders’ preferences for changes within criteria5. 5. Weighting criteria: eliciting stakeholders’ preferences between criteria. 6. Calculating aggregate scores: using the alternatives’ scores on the criteria and the weights for the criteria to get “total value” by which the alternatives are ranked. 7. Dealing with uncertainty: performing uncertainty analysis to understand the level of robustness of the MCDA results. 8. Reporting and examination of findings: interpreting the MCDA outputs, including uncertainty analysis, to support decision making.

5 This is correct for quantitative MCDA (i.e. where numbers are assigned), but many countries use a qualitative MCDA where committees discuss the elements but don’t assign weights. Worth making this distinction

Page 99 of 109

b) Program Budgeting and Marginal Analysis

Program Budgeting and Marginal Analysis (PBMA) is a framework that helps decision-makers to reallocate resources so that benefits are maximized. This approach is premised on two key criteria, key technical criteria: ‘opportunity cost’ and ‘the margin’. Meeting these criteria allows judgments to be made around fundamental questions for priority setting, such as where to spend extra resources when faced with a fixed budget, or where best to cut expenditure. The starting point for PBMA is to use current budgets to set out how resources are currently being used. Analysts can then decide to either change how resources are used within the existing budget, or to allocate additional resources to meet needs. PBMA can thus be split into two components: 1) programme budgeting, an appraisal of past resource allocation in specified programmes, with a view to tracking future resource allocation in those same programmes; and 2) marginal analysis, the appraisal of the added benefits and added costs of a proposed investment or the lost benefits and lower costs of a proposed disinvestment. PBMA has eight stages:

1. Choose a set of meaningful programmes or interventions; 2. Identify current activity and expenditure in those programmes or interventions; 3. Think of improvements; 4. Weigh up incremental costs and incremental benefits and prioritize a list; 5. Consult widely; 6. Decide on changes; 7. Effect the changes and; 8. Evaluate progress.

The main challenge with this approach is that it requires a lot of data which may be missing or not perfect in the South African setting. c) Accountability for reasonableness

Accountability for reasonableness (AFR) is an ethical framework for priority setting aimed at ensuring that the process towards setting priorities is fair; and that the actual decided-upon priorities are based on reasons that are communicated to all relevant parties involved. AFR thus provides decision makers with an approach to consider and jointly discuss competing values in the priority-setting process and is based on the concept of “procedural justice”. According to AFR, a process for setting priorities is legitimate and fair if it meets four conditions:

1. Relevance – decisions are founded in the values of all concerned and considered important. 2. Publicity – priority-setting decisions and the reasons behind them are transparent and are made public. 3. Appeals and revision – stakeholders are given an opportunity to appeal against decisions, propose revisions, and receive a reasoned response. 4. Enforcement – leadership to ensure that the first three criteria are adhered to.

As AFR is focussed on the process of decision making, it can potentially incorporate any number of technical criteria or methods, including those listed herein, such as MCDA and QALY league tables. d) QALY league tables

A Quality Adjusted Life Year (QALY) league table is an approach aimed at allowing priority setting of possible changes in health care programs when these are competing for limited resources, and choices have to be made about where to make changes. The ‘league table’ ranks different procedures/interventions according to the ‘cost per QALY’ of implementing these procedures.

Page 100 of 109

The league table comprises a list of healthcare interventions in ascending order (from low to high) of their incremental cost-effectiveness ratio (ICER) - expressed as cost per QALY gained. If the goal of the healthcare system is to generate as many QALYs as possible, then a cost per QALY league table represents a prioritised list of interventions, from high priority (low cost per QALY) to low priority (high cost per QALY). The resource allocation decision rule underlying the use of these tables is that changes in programs should be implemented on the rank order basis of ascending cost pet QALY.

An example of a QALY league table for the UK is shown in Table 2. With interventions ranked according to their cost per QALY, decisions are made regarding the inclusion of all interventions in a benefits package only if they meet a certain threshold. For example, the UK cost per QALY gained threshold £50,000, thus in Table 2, the interventions that fall above this threshold are not included in the benefits package.

Table 2. Example of a QALY league table for the UK Intervention Cost/QALY gained (£) GP advice to give up smoking 500 Pacemaker implant 1,500 Hip replacement 2,000 Colorectal cancer screening 2,500 Breast cancer screening 3,500 Sildenafil (Viagra) 4,000 Heart transplantation 10,000 Hospital haemodialysis 25,000 Surgery for intra-cranial tumours 150,000 Interferon for multiple sclerosis 800,000

e) Target setting

Target setting is mainly used by national governments and international organizations such as the WHO. It requires setting broad goals for health, then breaking these into specific objectives and interventions, with success measured by achievement of the broad health goals. An example of this is the millennium development goals (MDG) or sustainable development goals (SDG) process.

Box 1 shows some SDG targets for health outlined in the United Nations development agenda. Reaching these goals requires targeting resources in such a way that priority interventions are aligned to make the necessary gains towards attaining the suggested targets. Each one of these goals has a specific set of indicators that must be met to show progress.

Box 1. Sustainable development goal 3: Health

•3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births •3.2 By 2030, end preventable deaths of new-borns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births and under-5 mortality to at least as low as 25 per 1000 live births.

Page 101 of 109

•3.7 By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes. •3.8 Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

f) Core Services

The idea with this approach is that priority setting is best approached through identifying core or necessary care. Certain health services are said to be essential, others less so. The essential services should ideally be made available to all, (often by the state) and the discretionary ones paid for by those individuals who wish to have them and can afford to have them.

4. The Committee’s Recommendations

The key message underlined in the literature and reiterated in this report is that all methods of priority setting have limitations and that different methods have to be used, depending on the particular circumstances. To make the recommendation on the appropriate methods for priority setting, the Committee considered how these methods apply the suggested guiding principles (Table 3) as well as the level of intensity and effort required to apply each method.

The recommendation by the Committee is that a mix of methods must be used to set priorities. The primary method recommended for the PMB review is MCDA, which embodies all the chosen guiding principles, but also incorporates the other priority setting methods in its iterative processes. However, this must be used with other approaches to circumvent the challenges associated with MCDA.

An example regarding the above is where list of core services or non-negotiables is identified, based on health needs in the country or key attributes of scheme beneficiary populations. From there, other criteria can then be applied. The Committee notes that the spirit of the AFR framework, which embodies transparency and justice has been well incorporated in the current PMB review process. The process has been inclusive, taking on board the views of multiple stakeholders, particularly in setting up the Priority Setting Committee. This should be the underlying approach taken to build trust, which is necessary to any successful priority setting process.

Table 3: Linking the adopted principles to priority setting methods Principles MCDA PBMA AFR QALY Target Core league setting services tables Health needs       Right to access health care   services Financial Risk Protection   Sustainability and   Affordability Clinical and Cost    Effectiveness; Efficiency

Page 102 of 109

ANNEXURE B: PROCESS FOR REVIEWING THE PACKAGE

1.Background

This section of the report provides an overview of the envisaged PMB review process based on the principles and methods recommended by the Priority Setting Committee.

This proposal suggests three parallel processes that must be followed to allow for incremental changes to the benefit package that will progressively improve the system in accordance with available resources and delivery systems. The central objective of this proposal is to introduce primary care as a core element of the PMB package, and it recommends a rapid mechanism to achieve this. In addition, a process for the complete review of the package which will take a much longer period to complete, is also suggested. The approach of following these separate processes is that it will allow for the rapid implementation of specific interventions. In contrast, a formal fully-fledged review requires more resources and will take much longer to execute.

For the priority setting process to be successful;

• It is essential to create trust in the process. This will be aided by ensuring that the process is transparent, inclusive, and impartial. • The process must actively enable participation and facilitate dialogue across groups and be cognisant of the fact that stakeholders are not equal in power: gender issues, marginalised groups, language, and information gaps must be catered for. • Facilitators must ensure that the playing field in which the priority‐setting game is played is level. • In the medium term, mechanisms must be applied to strengthen individual capacity; strengthen institutional capacity; overcome gender barriers to participation and facilitate inclusion of marginalised groups. • Engagement with stakeholders must happen early and often. • Mechanisms must be applied to ensure that participation is not only inclusive, but meaningful in that it allows the views of participants to be reflected in the ultimate decisions.

The processes envisaged are:

i. Identify specific preventive measures, using the recommended principles. ii. Identify and review the current primary care benefits included in the PMB package. iii. Undertake a substantive review of the PMB package using MCDA.

Figure 1 below shows that the first two processes, i.e. the introduction of new preventive measures and the review of existing PHC benefits can be done rapidly by existing CMS personnel and specialist stakeholder committees.

The third process shown in Figure 1, whereby the full package is reviewed through the application of a thorough MCDA process which includes health technology assessment; require stronger institutional capacity. It is important to note that the work to assess affordability and cost of the PMB must start immediately to avoid delays in the finalisation of each of the three processes. Similarly, the preparation for the draft regulations must also start immediately to avoid delays.

Page 103 of 109

Figure 1: High level description of three processes identified to support the PMB review with an indication of resource requirements and expected duration of each

Page 104 of 109

2. Approaches towards the development of a comprehensive service

Figure 2 below shows the overlap of service benefits between medical scheme benefits and the public sector. The diagram serves to assist in describing the different approaches for the selection of benefits for the PMB package. The priority setting sub-committee favours an MCDA6 approach for the development of revised PMBs; however, for practical reasons a mix of methods7 will be used. The sections below describe a process whereby primary care services are included as a core element; and other interventions are added.

Figure 2: Overlap between services in the medical scheme and public health areas

Considering Figure 2 above, three processes are proposed:

- The first process is the identification of a set of preventive interventions with evidence showing that these interventions assist in curbing downstream costs. These interventions will focus on a new set of PHC benefits that are not currently covered in the PMBs and must be identified for rapid implementation. These benefits will be selected using a target setting approach8 and may include immunisations and other preventive medicine. - The second proposed process is the identification of Primary Health Care (PHC) elements included in the current PMB package that overlap with the NDOH package (this includes the current Chronic Disease List (CDLs) and Emergency Care). Using the core service approach and the MCDA approach; the existing overlapping benefits must be reviewed and a single set of common definitions developed for PHC benefits currently covered through the PMBs in the public and private sectors.

6 Multi-Criteria Decision Analysis (MCDA) is a general framework for supporting complex decision- making situations with multiple and often conflicting objectives that stakeholder groups and/or decision- makers value differently.6 MCDA is a valuable tool that we can apply to many complex decisions. It is most applicable to solving problems that are characterised as a choice among alternatives. The Oregon set of benefits were selected through the application of an MCDA approach. 7 Elements of a range of methodologies will be applied where applicable; these include Program Budgeting and Marginal Analysis (PBMA), Accountability for reasonableness (AFR), QALY league tables, Target setting, and Core services. 8 Target setting is mainly used by national governments and international organisations such as the WHO. It requires setting broad goals for health, then breaking these into specific objectives and interventions, with success measured by achievement of the broad health goals. An example of this is the millennium development goals (MDG) or sustainable development goals (SDG) process. Interventions that support the achievement of these targets are then selected as part of the benefit package.

Page 105 of 109

- Finally, a fully-fledged MCDA approach must be applied to review the PMBs in their entirety to develop a single set of benefits for all South Africans. This process will take the longest time to complete. Applying the MCDA approach, critical DTPs will be reviewed to improve clarity.

Parallel to the commencement of the three processes, the costing committee will start the economic analysis that will assist with establishing affordability levels for 1; the full PMB package, 2; a low-cost benefit option package, and 3; a package of PHC services that may be purchased by the NDoH from private providers for government patients9.

Similarly, the PMB review legal team must consider other changes to the regulations that are required to improve clarity to avoid undue delays in making the regulations after the package has been finalised.

2.1 Process 1 - New preventive measures to curb downstream costs

The first process recommended above is that a list of new benefits that are not currently covered in the PMBs but do exist in the NDoH package must be identified. These interventions may include, for example, all vaccinations in the Department of Health's Extended Programme of Immunisation (EPI SA) as well as contraception. Screening for certain cancers and other conditions may also be included based on the recommended principles and methodology. A target setting approach will be used for this set of interventions.

Specific considerations in the costing and affordability assessment must include an assessment at an item level, detailing information on how much of these costs are currently paid for by schemes as part of a PMB benefit10; how much is covered through discretionary benefits; and how much will have to be funded through contribution increases.

It is important to do the analysis above at the benefit option level, in order to understand the impact on low cost options, and the potential impact on cross subsidies flowing from middle options to low cost options. In this respect it is important to consider the provisional HMI recommendations aimed at avoiding the fragmentation of risk pools.

To improve the sustainability of these interventions, the specific reforms to reduce costs are considered in more detail in Section D and must be applied over time.

2.2 Process 2 - Review and update existing PHC benefits covered through PMBs that are also included in the NDoH package

The second process is to identify the range of PHC benefits that are currently offered through the PMBs, that are also covered in the NDoH package. These include the list of chronic diseases covered as PMBs (CDLs). Other conditions that are partially covered include elements of the HIV and TB management. Emergency medical conditions are also covered through the PMBs.

This second process must focus on the updating of existing benefits to ensure that these benefits are in line with current evidence based medical practice. For this part of the package, a combination of a target setting, and core services approach, must be followed to identify those priority interventions that address South Africa’s quadruple disease burden, and meet the constitutional requirement of access to emergency care.

9 The costing committee is developing a costing methodology 10 DTP 960M: “Cervical and breast cancer screening Cervical smears; periodic breast Examination” is currently a PMB intervention and screening and preventative therapy for TB is covered for HIV patients

Page 106 of 109

As is the case with the new preventive measures considered in section 1.6.1 above, the price of medicines for these interventions must be re-negotiated. This is critical to ensure that the care is expanded with increased volumes, while the cost of the PMB package is held at an affordable level.

The updating of the CDLs can be done through the updating of the outdated algorithms that were developed in 2010 (in consultation with appropriate clinical specialists) and publication of the updates for public comment. Specialist committees11 must then interrogate the comments on the published draft algorithms and develop updated algorithms for review, approval and implementation by the PMB Review Committee.

In the review of the emergency medical condition definition, special care must be taken to ensure that the coverage available under this benefit is clearly understood by providers and members of the public.

The work done by the EML committee must support the updating of these algorithms. The specific drugs used in the Standard Treatment Guidelines (STGs) should be included for coverage in the PMBs.

In the development of clinical guidelines in support of the CDL algorithms as considered in section D, specific attention must be given to the Health Benefits SA database developed for the NDoH by the Clinton Health Access Initiative, which will provide information on existing guidelines.

As is the case with the new preventive measures discussed in section 1.6.1 above, affordability assessment of these changes must also be done at the medical scheme option level. An assessment must be made as to whether the savings from the acquisition of medicines at re-negotiated prices can be used to offset cost increases associated with the additional PMB benefits for members in low cost benefit options.

In some areas the STGs are not adequate to cover all conditions that may be included in the PMBs. Full International guidelines may be applicable, but some of the guidelines are too comprehensive for PMB purposes and are often developed without considering costs. International guidelines must therefore be specifically for the South African third-party payer environment. It is important to be aware that many treatment guides without consideration of the availability of resources, are not affordable in the South African context. International and professional guidelines are often comprehensive and all-encompassing but cannot be applied blindly for a minimum benefit in the South African context.

2.3 Process 3 - Review the full PMB package

The third process is a complete MCDA process for the development of a benefit package that has never been implemented in South Africa; therefore, the process outlined here will have to be fine-tuned as the process progresses. The proposed process is based on review of practices in countries such as Thailand, United Kingdom and the Oregon (2) state.

The process involves reviewing the current DTPs. During the 2008 to 2010 PMB review, changes were made to the DTPs in the draft regulations, which have not been published for comments to date. Changes included the addition of some DTPs, revisions of some, as well as a renumbering and a re-arrangement of the manner in which they were presented. These changes were made in consideration of appeal committee rulings, specific recommendations from specialist committees, members of the public and other stakeholders. Many of these draft changes reflect changes in medical practice.

11 More detail on the 13 specialist subcommittees and the scope of their work in 2009 is available at: http://medicalschemes.com/files/PMB%20Review/Terms_of_Reference_ClinicalAdvisoryComm20090808.pdf

Page 107 of 109

The impact on cost and affordability must be estimated before final acceptance of these changes. These proposed changes must again be reviewed by specialist committees, since some of the changes proposed in 2009 may no longer reflect current medical practice.

It is important to note that the need to care for rare diseases or orphan diseases is not likely to be adequately addressed through the PMB review process, therefore, other funding and service delivery mechanisms must be developed to address this important concern.

3. Proposed Timeframes

The proposal put forth is that work on processes 1 and 2 must begin in February 2019 as depicted in figure 3. Between February and March, the different stakeholders together with the CMS will consider all preventative measures currently available (i) under the PMBs, (ii) available in schemes as discretionary benefits (ii)in the public sector, and (iv) under both public and private sector) and apply the methodology described above to come up with a preventative and PHC package.

It is envisaged that iterative costing work will begin in March as work on the preventative and PHC package progresses.

Appraisal of the preventative and PHC will begin in April 2019 with the aim of finalising in March 2020.

Figure 3: Proposed Timeframes for the outlined processes.

February 2019 March 2019 April 2019- March 2020

• Process 1: Review • Prioritisation of • Appraisal & of preventative preventative and Finalisation of PHC package PHC continue package • Process 2: Review • Costing of • Review of full PMB of PHC preventative and package PHC package • Costing of full begins package

Page 108 of 109

Page 109 of 109