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