Top Secret Presentation on the White Paper on the National Health

PRESENTATION TO THE 3rd South African Nurses Conference

National Health Insurance (NHI)

Universal Health Coverage

The Third Transition of Health 25 February 2016 WHAT IS NHI?

• NHI is a health financing system that pools funds to provide access to quality health services for all South Africans based on their health needs and irrespective of their socio-economic status

• This is the only way to guarantee Universal Health Coverage (UHC) as adopted in September 2015 as one of the United Nations Sustainable Development Goals, NDP, African Claims (1943), Gluckman Commission (1944), Freedom Charter (1955)

2 Historical Context of Health Care Financing Reforms South Africa has a rich history of several proposals and attempts to implement health financing reforms namely:

• the 1928 Commission of Old Age Pension and NHI; • 1941 Collie’s Committee of Inquiry into NHI; • the 1943 African Claims that proposed equal treatment in the scheme of Social Security; • the Gluckman’s National Health Services Commission of 1943 to 1944 that proposed NHI (Dr Henry Gluckman); • The Freedom Charter as adopted by the Congress of the People, 1955; • Ministerial Committee on Health Care Financing, 1994; • the Ministerial Committee of Inquiry into NHI,1995 (Broomberg and Shisana Report); • Social Health Insurance Working Group 1997; • Taylor’s 2002, Committee of Inquiry into a Comprehensive Social Security System; • Ministerial Task Team on Social Health Insurance and now the current Ministerial Advisory Committee on NHI, 2009.

3 African Claims Under The African Claims in South Africa the Charter on Health states :- “a drastic overhauling and re-organisation of the health services of the country with due emphasis on preventive medicine with all that implies in modern public health sense.., strongly urged the establishment of free medical and health services for all sections of the population; …the establishment of a system of School Medical Service with full staff of medical practitioners, nurses and other health visitors… increased hospitals and clinic facilities both in the rural and in urban areas; Increased facilities for the training of African doctors, dentists, nurses, sanitary inspectors, health visitors (and) a coordinated control finance of health services for the whole Union.”(14 December, 1943).

4 Freedom Charter There shall be Housing, Security and Comfort for All: “A preventative health scheme shall be run by the state; Free medical care and hospitalisation shall be provided for All with special care for mothers and young children”

5 Declaration of Alma-Ata International Conference on Primary Health Care, Alma- Ata, USSR, 6-12 September 1978 Declaration: I The Conference strongly reaffirms that health, which is a state of complete physical, mental and social wellbeing, and not merely the absence of disease or infirmity, is a fundamental human right and that the attainment of the highest possible level of health is a most important world-wide social goal whose realization requires the action of many other social and economic sectors in addition to the health sector. II The existing gross inequality in the health status of the people particularly between developed and developing countries as well as within countries is politically, socially and economically unacceptable and is, therefore, of common concern to all countries. HEALTH FOR ALL BY THE YEAR 2000 6 National Development Plan

7 UN Sustainable Development Goals (SDGs) • Declaration: “On behalf of the People we serve, we have adopted a historic decision on a comprehensive, far-reaching and people-centred set of Universal and transformative goals and target. We commit ourselves to working tirelessly for full implementation of this agenda by 2030 • As we embark on this great collective journey, we pledge that no one will be left behind. Recognising that dignity of the human person is fundamental, we used to see the goals and targets met for all nations and people, and for all segments of society. And we will endeavour to reach the furthest behind first”.

8 UN Sustainable Development Goals (SDGs) contd.

• “This is an agenda of unprecedented scope and significance. It is accepted by all countries and is applicable to all, taking into account different national realities, capacities and levels of development and respecting national policies and priorities. These are Universal goals and targets which involve the entire world, developed and developing countries alike”

9 UN Sustainable Development Goals (SDGs) contd.

• Goal 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”.

10 WHY UHC? But what is UHC?

THE PURPOSES OF UNIVERSAL HEALTH CARE COVERAGE ARE: • to meet population health needs; • to remove financial barriers to health care; • to reduce incidence of catastrophic health expenditure • this should facilitate the attainment of national and internationally agreed health goals; and • ultimately contribute to better quality of life, poverty alleviation and human development

11 Global Structural Problems of Health Care Systems Dr Margaret Chan Director-General (WHO) • That is – (i) rising health care costs yet poor access to essential medicines, especially affordable generic products; (ii) an emphasis on cure that leaves prevention by the wayside; (iii) costly private care for the privileged few, but second- rate care for everybody else; (iv) grossly inadequate numbers of staff, or the wrong mix of staff; (v) weak or inappropriate information systems; (vi) weak regulatory control; and (vii) schemes for financing care that punish the poor.

12 WHAT IS WRONG WITH THE PRESENT SYSTEM?

13 WHAT IS WRONG WITH THE PRESENT SYSTEM?-WHOLE SYSTEM

100%

80%

60%

40%

20%

0% % share of benefit % share of need

Poorest 20% of population Second poorest 20% Middle 20% Second richest 20% Richest 20%

14 WHAT IS WRONG WITH THE PRESENT SYSTEM? (Private Sector)

15 16 17 18 19 20 21 22 23 24 25 26 27 Cost per hospital day as a ratio of GHI (2012)

4.0%

3.5%

3.0%

2.5%

2.0%

1.5%

1.0%

0.5%

0.0%

28 Cost of MRI Scan as a ratio of GHI (2012)

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0%

29 Cost of Hip Replacement as a ratio of GHI (2012) 80%

70%

60%

50%

40%

30%

20%

10%

30 Cost of Angiogram as a ratio of GHI (2012) 2.5%

2.0%

1.5%

1.0%

0.5%

0.0% Canada Switzerland Spain France South Chile South U.S.A. Africa_Adj Africa 31 Cost of Bypass surgery as a ratio of GHI (2012)

32 Cost of Normal Vaginal Delivery as a ratio of GHI (2012)

33 Cost of Caesarean Section as a ratio of GHI (2012) 25.0%

20.0%

15.0%

10.0%

5.0%

0.0%

34 35

Charges (Complaints laid with the Minister) • R18,000 for D&C • R30,000 for peri-anal abscess • R67,000 for evaluation after a car accident (patient came into hospital walking) • R500,000 for a laparatomy for peritoneal abscess (in addition separate surgeon’s fee of R23,000; separate anesthetists fee of R3,000) Another R700,000 for repeat laparatomy (but patient died before that) 38 Some Practices Bordering on Criminality

• For instance – Root canal treatment in a 10 year old child – Motive? – R20,000 procedure instead of R200

39 WHAT IS WRONG WITH THE PRESENT SYSTEM? (Public Sector)

40 What is wrong in the Public Sector

1. Human Resources: – Wrong people appointed in wrong places – Patronage and cronyism – Poor planning , development and management of HR 2. Financial Management - Unfavourable Audit outcomes except at National and 3 Provinces 3. Procurement / Supply Chain – Simplest of equipment and devices unavailable or out of order for long periods of time – Absence of most essential medicines and drugs due to corruption or non- payment of pharmaceutical companies – Huge tenders issued for non-essential equipment (wrong procurement choices) 4. Infrastructure – Poor or non-existent maintenance of infrastructure – Collapse of essential infrastructure due to corrupt procurement practices – Poor workmanship in the construction of new infrastructure

41 Developments in Post-Colonial Africa

• Ghana – Kwame Nkrumah, 1957 • Angola – Augustinoh Neto, 1975 • South Africa – Nelson Mandela, 1996

42 Dr Sambo’s address • WE WISH TO PROPOSE FOUR MAJOR THRUSTS FOR ATTAINING UNIVERSAL HEALTH COVERAGE: • First, strengthening the capacities of public health infrastructure to provide effective, safe, and quality health services. Infrastructure includes “staffing, buildings, technologies; utilities such as power and water supply; waste management; transport and communication; and FINANCING investments, maintenance and recurring costs”. Health infrastructure entails public investments and Governments will have to explore innovative ways of harnessing the resources of the private sector, NGOs and communities.

43 Infrastructure Optimization Tool Kit applied for the selection of clinics to be built in four provinces of EC, FS, LP and MP NHI Districts

44 Infrastructure Audit-Prioritization of Clinics for replacement, upgrading and Repairs-NHI District, Vhembe LP

3- WEIGHTED 1 <20 Very poor 1- AVERAGE POPULATION CONDITION OF MORE THAN 5KM NATIONAL DEPARTMENT OF HEALTH 2 20 - 40 Poor 2 -TOTAL THE FACILITY FROM THE ANALYSIS OF THE NATIONAL HEALTH AUDIT DATA TO GUIDE THE NEED FOR NEW/REPLACEMENT CLINICS 3 40 - 60 Fair SPACE FACILITY Data sorted by district, average condition of the facilities, and total space score 4 60 -80 Good SCORE

to select clinics that are in very poor condition for possible replacement. 5 >80 Very good Space

lp Vhembe District Municipality lp Makhado Local Municipality Louis Trichardt Clinic 60.0% 50.0% 50.0% 60.0% 6.0% 50.0% 0.0% 60.0% 44.0% 50.0% 50.0% 60.0% 60.0% 50.0% 100.0% 75.0% 40% 4 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Magwedzha Clinic 40.0% 40.0% 60.0% 60.0% 35.0% 60.0% 30.0% 60.0% 20.0% 40.0% 50.0% 60.0% 60.0% 60.0% 50.0% 100.0% 75.0% 41% 4 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Kulani Clinic 40.0% 50.0% 60.0% 60.0% 20.0% 60.0% 58.0% 52.0% 40.0% 50.0% 60.0% 60.0% 50.0% 60.0% 100.0% 100.0% 100.0% 42% 5 #N/A lp Vhembe District Municipality lp Mutale Local Municipality Thengwe Clinic 46.0% 100.0% 100.0% 100.0% 20.0% 20.0% 100.0% 20.0% 58.0% 100.0% 20.0% 0.0% 68.0% 100.0% 0.0% 0.0% 0.0% 42% 1 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Makonde Clinic 26.0% 60.0% 60.0% 46.0% 60.0% 56.0% 60.0% 58.0% 36.0% 60.0% 56.0% 60.0% 38.0% 52.0% 50.0% 100.0% 75.0% 43% 4 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Sibasa Clinic 40.0% 60.0% 60.0% 40.0% 50.0% 44.0% 40.0% 44.0% 40.0% 60.0% 46.0% 60.0% 40.0% 60.0% 100.0% 100.0% 100.0% 43% 5 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Mulenzhe Clinic 60.0% 80.0% 80.0% 80.0% 30.0% 60.0% 40.0% 60.0% 40.0% 80.0% 60.0% 60.0% 40.0% 60.0% 50.0% 100.0% 75.0% 46% 4 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Manavhela Clinic 52.0% 60.0% 60.0% 60.0% 50.0% 50.0% 60.0% 50.0% 52.0% 60.0% 46.0% 40.0% 32.0% 50.0% 100.0% 100.0% 100.0% 46% 5 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Dzingahe Clinic 56.0% 60.0% 60.0% 60.0% 56.0% 42.0% 58.0% 54.0% 54.0% 60.0% 20.0% 60.0% 56.0% 60.0% 100.0% 100.0% 100.0% 48% 5 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Olifantshoek Clinic 60.0% 60.0% 60.0% 60.0% 58.0% 40.0% 60.0% 50.0% 58.0% 60.0% 6.0% 60.0% 60.0% 50.0% 100.0% 100.0% 100.0% 48% 5 9 384 lp Vhembe District Municipality lp Makhado Local Municipality Kutama Clinic 50.0% 60.0% 60.0% 60.0% 50.0% 46.0% 50.0% 40.0% 50.0% 60.0% 46.0% 60.0% 50.0% 50.0% 50.0% 100.0% 75.0% 49% 4 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Riverplaats Clinic 48.0% 60.0% 60.0% 60.0% 46.0% 58.0% 56.0% 60.0% 48.0% 60.0% 58.0% 60.0% 52.0% 28.0% 100.0% 100.0% 100.0% 50% 5 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Sterkstroom Clinic 33.0% 60.0% 60.0% 60.0% 52.0% 60.0% 60.0% 60.0% 56.0% 60.0% 60.0% 60.0% 58.0% 58.0% 0.0% 0.0% 0.0% 52% 1 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Beaconsfield Clinic 58.0% 60.0% 60.0% 60.0% 60.0% 40.0% 60.0% 50.0% 58.0% 60.0% 26.0% 60.0% 60.0% 60.0% 50.0% 100.0% 75.0% 52% 4 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Tshakhuma Clinic 48.0% 60.0% 60.0% 60.0% 54.0% 52.0% 58.0% 56.0% 52.0% 60.0% 54.0% 60.0% 54.0% 56.0% 100.0% 100.0% 100.0% 52% 5 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Tshimbupfe Clinic 48.0% 60.0% 60.0% 60.0% 48.0% 52.0% 60.0% 50.0% 54.0% 60.0% 56.0% 60.0% 58.0% 60.0% 50.0% 100.0% 75.0% 53% 4 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Matiyani Clinic 60.0% 56.0% 60.0% 60.0% 46.0% 56.0% 54.0% 50.0% 52.0% 56.0% 56.0% 60.0% 54.0% 50.0% 50.0% 0.0% 25.0% 54% 2 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Matsa Clinic 50.0% 60.0% 60.0% 56.0% 60.0% 54.0% 60.0% 60.0% 52.0% 60.0% 52.0% 60.0% 54.0% 60.0% 50.0% 100.0% 75.0% 54% 4 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Dzwerani Clinic 60.0% 50.0% 60.0% 50.0% 54.0% 50.0% 50.0% 60.0% 60.0% 50.0% 40.0% 60.0% 56.0% 60.0% 50.0% 0.0% 25.0% 54% 2 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Mavambe Clinic 60.0% 60.0% 60.0% 60.0% 50.0% 56.0% 60.0% 60.0% 60.0% 60.0% 40.0% 60.0% 60.0% 60.0% 100.0% 100.0% 100.0% 54% 5 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Vhurivhuri Clinic 48.0% 60.0% 60.0% 60.0% 58.0% 60.0% 60.0% 60.0% 50.0% 60.0% 58.0% 60.0% 58.0% 60.0% 50.0% 100.0% 75.0% 54% 4 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Mhinga Clinic 60.0% 50.0% 60.0% 50.0% 37.0% 48.0% 58.0% 58.0% 58.0% 50.0% 59.0% 60.0% 58.0% 60.0% 50.0% 100.0% 75.0% 54% 4 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Muledane Clinic 60.0% 80.0% 80.0% 60.0% 40.0% 56.0% 80.0% 60.0% 40.0% 80.0% 74.0% 80.0% 60.0% 60.0% 50.0% 100.0% 75.0% 55% 4 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Khomela Clinic 50.0% 60.0% 20.0% 60.0% 56.0% 50.0% 60.0% 58.0% 58.0% 60.0% 56.0% 62.0% 54.0% 40.0% 100.0% 100.0% 100.0% 55% 5 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Murangoni Clinic 60.0% 60.0% 60.0% 60.0% 35.0% 50.0% 60.0% 60.0% 60.0% 60.0% 60.0% 20.0% 60.0% 20.0% 0.0% 0.0% 0.0% 55% 1 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Nghezimani Clinic 60.0% 60.0% 60.0% 60.0% 60.0% 60.0% 40.0% 60.0% 60.0% 60.0% 35.0% 60.0% 60.0% 60.0% 100.0% 100.0% 100.0% 55% 5 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Sambandou Clinic 52.0% 60.0% 60.0% 60.0% 56.0% 46.0% 40.0% 60.0% 54.0% 60.0% 58.0% 60.0% 56.0% 60.0% 0.0% 0.0% 0.0% 55% 1 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Lambani Clinic 52.0% 60.0% 60.0% 60.0% 58.0% 40.0% 58.0% 50.0% 54.0% 60.0% 54.0% 60.0% 58.0% 60.0% 50.0% 0.0% 25.0% 55% 2 1 248 600 lp Vhembe District Municipality lp Makhado Local Municipality Valdezia Clinic 50.0% 60.0% 60.0% 60.0% 54.0% 60.0% 60.0% 60.0% 58.0% 60.0% 60.0% 60.0% 54.0% 60.0% 100.0% 100.0% 100.0% 55% 5 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Tshifudi Clinic 60.0% 60.0% 60.0% 60.0% 67.0% 54.0% 60.0% 60.0% 60.0% 60.0% 30.0% 60.0% 60.0% 60.0% 0.0% 0.0% 0.0% 55% 1 #N/A lp Vhembe District Municipality lp Makhado Local Municipality Vuvha Clinic 52.0% 60.0% 58.0% 60.0% 54.0% 52.0% 58.0% 57.0% 54.0% 60.0% 60.0% 60.0% 58.0% 57.0% 50.0% 100.0% 75.0% 56% 4 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Mukula Clinic 60.0% 60.0% 60.0% 60.0% 58.0% 60.0% 40.0% 60.0% 40.0% 60.0% 60.0% 60.0% 60.0% 60.0% 0.0% 0.0% 0.0% 56% 1 #N/A lp Vhembe District Municipality lp Thulamela Local Municipality Ntlhaveni C Clinic 55.0% 60.0% 60.0% 52.0% 54.0% 58.0% 57.0% 60.0% 56.0% 60.0% 58.0% 60.0% 56.0% 60.0% 50.0% 0.0% 25.0% 56% 2 #N/A 45 lp Vhembe District Municipality lp Thulamela Local Municipality Tshisaulu Clinic 60.0% 80.0% 80.0% 80.0% 60.0% 56.0% 40.0% 40.0% 60.0% 80.0% 40.0% 80.0% 60.0% 80.0% 0.0% 0.0% 0.0% 56% 1 #N/A Infrastructure Audit-Prioritization of Clinics for replacement, upgrading and Repairs-NHI District, Gert Sibande, MP

to select clinics that are in very poor condition for possible replacement. 5 >80 Very good Space

lplp Vhembe Vhembe District Municipality District Municipality lplp Makhado Makhado Local Municipality Local Municipality MuilaLouis Clinic Trichardt Clinic 60.0%60.0% 50.0%60.0% 50.0%58.0% 60.0%59.0% 6.0%58.0% 50.0%45.0% 0.0%58.0% 60.0%59.0% 44.0%60.0% 50.0%60.0% 50.0%80.0% 60.0%60.0% 58.0% 60.0%60.0% 50.0%100.0% 100.0%100.0% 75.0%100.0% 40%63% 45 #N/A#N/A mp Gert Sibande District mp Govan Mbeki Local Langverwacht Clinic 0.0% 20.0% 20.0% 60.0% 80.0% 20.0% 0.0% 20.0% 20.0% 20.0% 20.0% 20.0% 60.0% 20.0% 50.0% 0.0% 25.0% 36% 2 933 mp Gert Sibande District mp Msukaligwa Local New Scotland Clinic 60.0% 20.0% 60.0% 20.0% 40.0% 40.0% 20.0% 20.0% 60.0% 20.0% 60.0% 40.0% 20.0% 40.0% 50.0% 0.0% 25.0% 48% 2 #N/A mp Gert Sibande District mp Dipaleseng Local Greylingstad Clinic 80.0% 60.0% 60.0% 28.0% 32.0% 28.0% 46.0% 50.0% 46.0% 60.0% 58.0% 60.0% 26.0% 80.0% 100.0% 0.0% 50.0% 48% 3 186 073 mp Gert Sibande District mp Govan Mbeki Local Langverwacht Ext 14 Clinic 60.0% 60.0% 20.0% 60.0% 60.0% 20.0% 60.0% 40.0% 60.0% 60.0% 60.0% 20.0% 20.0% 20.0% 0.0% 0.0% 0.0% 52% 1 933 mp Gert Sibande District mp Albert Luthuli Local Carolina Clinic 60.0% 60.0% 60.0% 40.0% 80.0% 20.0% 0.0% 20.0% 60.0% 60.0% 20.0% 60.0% 60.0% 60.0% 0.0% 0.0% 0.0% 56% 1 370 719 mp Gert Sibande District mp Mkhondo Local Mkhondo Town Clinic 60.0% 0.0% 80.0% 80.0% 80.0% 60.0% 80.0% 60.0% 60.0% 0.0% 20.0% 80.0% 60.0% 80.0% 0.0% 100.0% 50.0% 56% 3 #N/A Mkhondo mp Gert Sibande District mp Albert Luthuli Local Silobela Clinic 60.0% 60.0% 80.0% 80.0% 80.0% 20.0% 20.0% 40.0% 60.0% 60.0% 60.0% 40.0% 20.0% 20.0% 100.0% 100.0% 100.0% 56% 5 0 mp Gert Sibande District mp Pixley Ka Seme Local Ezamokuhle Clinic 0.0% 80.0% 80.0% 80.0% 70.0% 80.0% 100.0% 80.0% 70.0% 80.0% 80.0% 70.0% 70.0% 80.0% 0.0% 0.0% 0.0% 58% 1 2 274 mp Gert Sibande District mp Albert Luthuli Local Fernie 1 Clinic 46.0% 76.0% 76.0% 76.0% 68.0% 62.0% 80.0% 60.0% 58.0% 76.0% 64.0% 70.0% 60.0% 60.0% 50.0% 0.0% 25.0% 59% 2 0 mp Gert Sibande District mp Mkhondo Local Driefontein Old Stands Clinic 52.0% 60.0% 70.0% 70.0% 76.0% 46.0% 60.0% 78.0% 54.0% 60.0% 70.0% 0.0% 56.0% 60.0% 50.0% 100.0% 75.0% 62% 4 48 534 mp Gert Sibande District mp Albert Luthuli Local Diepdale Clinic 44.0% 80.0% 80.0% 80.0% 50.0% 76.0% 80.0% 60.0% 64.0% 80.0% 74.0% 80.0% 80.0% 80.0% 0.0% 100.0% 50.0% 62% 3 0 mp Gert Sibande District mp Albert Luthuli Local Betty'sgoed Clinic 72.0% 80.0% 80.0% 72.0% 66.0% 68.0% 80.0% 80.0% 60.0% 80.0% 60.0% 80.0% 60.0% 80.0% 0.0% 100.0% 50.0% 64% 3 0 mp Gert Sibande District mp Albert Luthuli Local Glenmore Clinic 58.0% 80.0% 80.0% 78.0% 76.0% 76.0% 68.0% 70.0% 60.0% 80.0% 72.0% 70.0% 60.0% 80.0% 0.0% 0.0% 0.0% 65% 1 11 458 mp Gert Sibande District mp Msukaligwa Local Kwazanele Clinic 60.0% 60.0% 80.0% 66.0% 66.0% 74.0% 60.0% 80.0% 60.0% 60.0% 60.0% 60.0% 80.0% 60.0% 100.0% 100.0% 100.0% 65% 5 0 mp Gert Sibande District mp Govan Mbeki Local Emzinoni Clinic 79.0% 80.0% 78.0% 51.0% 62.0% 76.0% 80.0% 37.0% 74.0% 80.0% 80.0% 78.0% 40.0% 80.0% 100.0% 100.0% 100.0% 67% 5 0 mp Gert Sibande District mp Albert Luthuli Local Nhlazatshe 6 Clinic 60.0% 76.0% 80.0% 68.0% 80.0% 60.0% 80.0% 80.0% 60.0% 76.0% 58.0% 80.0% 80.0% 40.0% 50.0% 0.0% 25.0% 68% 2 94 429 Nhlazatshe 6 mp Gert Sibande District mp Mkhondo Local Derby/Rustplaas Clinic 40.0% 80.0% 80.0% 60.0% 80.0% 20.0% 0.0% 80.0% 60.0% 80.0% 80.0% 20.0% 80.0% 20.0% 0.0% 100.0% 50.0% 68% 3 #N/A mp Gert Sibande District mp Albert Luthuli Local Tjakastad Clinic 80.0% 0.0% 60.0% 60.0% 80.0% 60.0% 80.0% 0.0% 80.0% 0.0% 60.0% 80.0% 40.0% 80.0% 50.0% 0.0% 25.0% 68% 2 0 mp Gert Sibande District mp Albert Luthuli Local Avontuur Satellite Clinic 68.0% 20.0% 40.0% 40.0% 68.0% 60.0% 0.0% 60.0% 76.0% 20.0% 60.0% 40.0% 68.0% 40.0% 50.0% 100.0% 75.0% 68% 4 #N/A mp Gert Sibande District mp Albert Luthuli Local Fernie 2 Clinic 80.0% 80.0% 80.0% 70.0% 44.0% 68.0% 80.0% 64.0% 60.0% 80.0% 78.0% 76.0% 80.0% 60.0% 50.0% 100.0% 75.0% 68% 4 0 mp Gert Sibande District mp Albert Luthuli Local Swallowsnest Clinic 60.0% 80.0% 60.0% 80.0% 80.0% 70.0% 80.0% 70.0% 60.0% 80.0% 74.0% 80.0% 70.0% 80.0% 100.0% 100.0% 100.0% 69% 5 0 mp Gert Sibande District mp Msukaligwa Local Thussiville/MN Cindi Clinic 80.0% 80.0% 80.0% 61.0% 74.0% 74.0% 80.0% 80.0% 70.0% 80.0% 76.0% 80.0% 46.0% 80.0% 0.0% 0.0% 0.0% 69% 1 #N/A mp Gert Sibande District mp Msukaligwa Local Chrissiesmeer/Kwachibikhulu 80.0% 80.0% 80.0% 60.0% 80.0% 80.0% 80.0% 80.0% 60.0% 80.0% 88.0% 80.0% 40.0% 80.0% 0.0% 0.0% 70% 1 0 mp Gert Sibande District mp Msukaligwa Local Davel Clinic 74.0% 80.0% 80.0% 76.0% 80.0% 80.0% 80.0% 80.0% 60.0% 80.0% 60.0% 60.0% 76.0% 60.0% 50.0% 100.0% 75.0% 70% 4 0 mp Gert Sibande District mp Albert Luthuli Local Arnhemburg Clinic 80.0% 80.0% 80.0% 80.0% 68.0% 68.0% 74.0% 64.0% 56.0% 80.0% 68.0% 80.0% 80.0% 80.0% 100.0% 100.0% 100.0% 70% 5 #N/A mp Gert Sibande District mp Albert Luthuli Local Hartebeeskop Clinic 80.0% 80.0% 76.0% 68.0% 68.0% 60.0% 60.0% 70.0% 78.0% 80.0% 70.0% 80.0% 60.0% 80.0% 37.5% 100.0% 68.8% 71% 4 27 229 mp Gert Sibande District mp Lekwa Local Municipality Morgenzon Clinic 76.0% 60.0% 80.0% 80.0% 58.0% 80.0% 60.0% 80.0% 74.0% 60.0% 93.0% 60.0% 58.0% 60.0% 50.0% 100.0% 75.0% 72% 4 44 017 mp Gert Sibande District mp Lekwa Local Municipality Stanwest/Azalia Clinic 100.0% 100.0% 40.0% 60.0% 40.0% 80.0% 100.0% 100.0% 60.0% 100.0% 100.0% 100.0% 60.0% 100.0% 0.0% 0.0% 0.0% 72% 1 0 mp Gert Sibande District mp Msukaligwa Local Ermelo Clinic 60.0% 80.0% 60.0% 60.0% 80.0% 20.0% 80.0% 60.0% 60.0% 80.0% 80.0% 80.0% 80.0% 80.0% 100.0% 100.0% 100.0% 72% 5 920 609 mp Gert Sibande District mp Pixley Ka Seme Local Wakkerstroom Clinic 78.0% 80.0% 80.0% 80.0% 77.0% 70.0% 79.0% 70.0% 72.0% 80.0% 58.0% 80.0% 78.0% 80.0% 50.0% 0.0% 25.0% 73% 2 0 mp Gert Sibande District mp Mkhondo Local Dirkiesdorp Clinic 60.0% 80.0% 80.0% 80.0% 76.0% 70.0% 80.0% 80.0% 78.0% 80.0% 78.0% 40.0% 80.0% 40.0% 0.0% 0.0% 0.0% 74% 1 96 297 mp Gert Sibande District mp Albert Luthuli Local Nhlazatshe Clinic 80.0% 80.0% 80.0% 80.0% 68.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 66.0% 80.0% 50.0% 100.0% 75.0% 75% 4 94 429 mp Gert Sibande District mp Albert Luthuli Local Mooiplaas Clinic 78.0% 78.0% 80.0% 74.0% 79.0% 70.0% 60.0% 68.0% 76.0% 78.0% 76.0% 72.0% 70.0% 72.0% 50.0% 100.0% 75.0% 76% 4 0 46 mp Gert Sibande District mp Msukaligwa Local Emthonjeni Clinic (Msukaligwa) 80.0% 100.0% 60.0% 40.0% 80.0% 20.0% 80.0% 40.0% 80.0% 100.0% 60.0% 80.0% 80.0% 20.0% 50.0% 0.0% 25.0% 76% 2 #N/A Emthonjeni Infrastructure Audit-Prioritization of Clinics for replacement, upgrading and Repairs-NHI District, Thabo Mofutsanyane, FS

to select clinics that are in very poor condition for possible replacement.5 >80 Very good Space

External External Ceiling Plumbing Plumbing Plumbing Internal Waste Water Space Service Weighted Population External Walls Electrical Electrical Internal Walls Floor Material Roof Material Sewerage Waiting Total Space Average condition Total Space Identified by the Water supply Material Toilet Internal Water basins Water Supply Disposal and Patient more than 5km from District Sub-District Facility Condition Supply Condition Condition Condition Condition Condition Area Score Score of facilities Score province Condition Condition Condition Condition Condition Condition Condition needs Score facility Condition ec Oliver Tambo District ec Nyandeni Health sub- Isilimela Gateway 20.0% 80.0% 100.0% 80.0% 20.0% 20.0% 20.0% 20.0% 20.0% 80.0% 20.0% 20.0% 20.0% 20.0% 100.0% 0.0% 50.0% 20% 3 12 426 fs Thabo Mofutsanyane fs Mantsopa Local Excelsior Clinic 80.0% 80.0% 80.0% 80.0% 72.0% 60.0% 60.0% 60.0% 60.0% 80.0% 0.0% 80.0% 60.0% 76.0% 100.0% 100.0% 100.0% 54% 5 55 279 District Municipality Municipality

fs Thabo Mofutsanyane fs Maluti a Phofung Bolata Clinic 60.0% 80.0% 80.0% 60.0% 40.0% 60.0% 40.0% 80.0% 60.0% 80.0% 56.0% 80.0% 50.0% 0.0% 25.0% 55% 2 0 District Municipality Local Municipality fs Thabo Mofutsanyane fs Setsoto Local Matwabeng Clinic 60.0% 80.0% 60.0% 56.0% 60.0% 28.0% 60.0% 80.0% 44.0% 80.0% 68.0% 80.0% 50.0% 100.0% 75.0% 58% 4 0 District Municipality Municipality fs Thabo Mofutsanyane fs Setsoto Local Kokelong Clinic 80.0% 80.0% 80.0% 38.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 32.0% 80.0% 100.0% 100.0% 100.0% 62% 5 0 District Municipality Municipality fs Thabo Mofutsanyane fs Mantsopa Local Borwa Clinic 80.0% 60.0% 80.0% 60.0% 60.0% 50.0% 70.0% 60.0% 80.0% 60.0% 32.0% 60.0% 60.0% 60.0% 50.0% 100.0% 75.0% 62% 4 0 District Municipality Municipality fs Thabo Mofutsanyane fs Mantsopa Local Tweespruit Clinic 72.0% 80.0% 80.0% 80.0% 40.0% 68.0% 84.0% 80.0% 80.0% 80.0% 76.0% 80.0% 60.0% 80.0% 100.0% 100.0% 100.0% 66% 5 0 District Municipality Municipality fs Thabo Mofutsanyane fs Phumelela Local Vrede Clinic 60.0% 80.0% 76.0% 62.0% 64.0% 80.0% 60.0% 80.0% 80.0% 80.0% 68.0% 80.0% 50.0% 0.0% 25.0% 66% 2 153 478 District Municipality Municipality fs Thabo Mofutsanyane fs Maluti a Phofung Tebang Clinic 80.0% 80.0% 74.0% 72.0% 70.0% 80.0% 60.0% 80.0% 52.0% 70.0% 76.0% 60.0% 0.0% 0.0% 0.0% 68% 1 0 District Municipality Local Municipality fs Thabo Mofutsanyane fs Maluti a Phofung Malesaona Clinic 80.0% 80.0% 80.0% 56.0% 40.0% 80.0% 50.0% 60.0% 80.0% 80.0% 80.0% 64.0% 80.0% 100.0% 100.0% 100.0% 68% 5 1 952 District Municipality Local Municipality fs Thabo Mofutsanyane fs Maluti a Phofung Paballong Clinic 80.0% 80.0% 20.0% 62.0% 60.0% 80.0% 80.0% 76.0% 80.0% 60.0% 80.0% 68.0% 80.0% 100.0% 0.0% 50.0% 69% 3 0 District Municipality Local Municipality fs Thabo Mofutsanyane fs Maluti a Phofung Nthabiseng Clinic 80.0% 80.0% 80.0% 68.0% 40.0% 70.0% 60.0% 80.0% 70.0% 80.0% 74.0% 80.0% 100.0% 0.0% 50.0% 70% 3 0 District Municipality Local Municipality fs Thabo Mofutsanyane fs Maluti a Phofung Thaba Bosiu 70.0% 80.0% 70.0% 70.0% 68.0% 20.0% 80.0% 76.0% 80.0% 66.0% 76.0% 72.0% 66.0% 50.0% 0.0% 25.0% 71% 2 0 District Municipality Local Municipality Clinic fs Thabo Mofutsanyane fs Mantsopa Local Manyatseng 100.0% 80.0% 80.0% 100.0% 40.0% 80.0% 80.0% 80.0% 80.0% 80.0% 56.0% 60.0% 80.0% 100.0% 100.0% 100.0% 100.0% 71% 5 0 District Municipality Municipality Clinic fs Thabo Mofutsanyane fs Maluti a Phofung Makoane Clinic 60.0% 80.0% 80.0% 68.0% 50.0% 80.0% 80.0% 74.0% 80.0% 80.0% 80.0% 76.0% 60.0% 0.0% 0.0% 0.0% 72% 1 0 District Municipality Local Municipality fs Thabo Mofutsanyane fs Mantsopa Local Ikaheng Clinic 80.0% 80.0% 80.0% 80.0% 58.0% 60.0% 80.0% 80.0% 80.0% 80.0% 80.0% 76.0% 60.0% 80.0% 50.0% 100.0% 75.0% 72% 4 0 District Municipality Municipality fs Thabo Mofutsanyane fs Maluti a Phofung Intabazwe Clinic 80.0% 80.0% 80.0% 66.0% 72.0% 80.0% 80.0% 80.0% 62.0% 50.0% 72.0% 80.0% 50.0% 0.0% 25.0% 72% 2 #N/A District Municipality Local Municipality fs Thabo Mofutsanyane fs Phumelela Local Memel Clinic 72.0% 80.0% 74.0% 68.0% 78.0% 80.0% 72.0% 80.0% 72.0% 72.0% 76.0% 80.0% 50.0% 100.0% 75.0% 72% 4 #N/A District Municipality Municipality fs Thabo Mofutsanyane fs Mantsopa Local Hobhouse Clinic 80.0% 20.0% 40.0% 60.0% 56.0% 58.0% 74.0% 56.0% 72.0% 20.0% 80.0% 20.0% 74.0% 20.0% 0.0% 100.0% 50.0% 72% 3 0 District Municipality Municipality fs Thabo Mofutsanyane fs Maluti a Phofung Qholaqhwe Clinic 80.0% 80.0% 74.0% 62.0% 40.0% 80.0% 80.0% 80.0% 80.0% 68.0% 80.0% 74.0% 80.0% 50.0% 0.0% 25.0% 73% 2 0 District Municipality Local Municipality fs Thabo Mofutsanyane fs Dihlabeng Local Relebohile 62.0% 80.0% 60.0% 68.0% 74.0% 74.0% 80.0% 80.0% 74.0% 80.0% 80.0% 80.0% 74.0% 80.0% 100.0% 100.0% 100.0% 73% 5 0 District Municipality Municipality (Rosendal) Clinic fs Thabo Mofutsanyane fs Maluti a Phofung Namahali Clinic 80.0% 80.0% 62.0% 70.0% 64.0% 80.0% 80.0% 80.0% 80.0% 68.0% 72.0% 74.0% 72.0% 50.0% 0.0% 25.0% 74% 2 0 District Municipality Local Municipality fs Thabo Mofutsanyane fs Maluti a Phofung Boiketlo Clinic 80.0% 80.0% 50.0% 68.0% 64.0% 20.0% 80.0% 70.0% 80.0% 76.0% 80.0% 80.0% 80.0% 100.0% 0.0% 50.0% 75% 3 0 District Municipality Local Municipality fs Thabo Mofutsanyane fs Nketoana Local Petsana Petsana Clinic 80.0% 80.0% 80.0% 68.0% 80.0% 80.0% 72.0% 80.0% 80.0% 80.0% 74.0% 80.0% 100.0% 100.0% 100.0% 75% 5 0 District Municipality Municipality Clinic fs Thabo Mofutsanyane fs Maluti a Phofung Tina Moloi Tina Moloi Clinic 80.0% 80.0% 72.0% 70.0% 78.0% 100.0% 80.0% 76.0% 80.0% 77.0% 100.0% 72.0% 100.0% 50.0% 100.0% 75.0% 75% 4 0 District Municipality Local Municipality Clinic

fs Thabo Mofutsanyane fs Dihlabeng Local Paul Roux Paul Roux Clinic 60.0% 80.0% 80.0% 80.0% 80.0% 80.0% 0.0% 80.0% 76.0% 80.0% 80.0% 20.0% 80.0% 20.0% 50.0% 100.0% 75.0% 75% 4 #N/A 47 Deloitte District Municipality Municipality Clinic Infrastructure Audit-Prioritization of Clinics for replacement, upgrading and Repairs-NHI District OR Tambo, EC

3- WEIGHTED 1 <20 Very poor 1- AVERAGE POPULATION CONDITION OF MORE THAN 5KM NATIONAL DEPARTMENT OF HEALTH 2 20 - 40 Poor 2 -TOTAL THE FACILITY FROM THE ANALYSIS OF THE NATIONAL HEALTH AUDIT DATA TO GUIDE THE NEED FOR NEW/REPLACEMENT3 40 - 60 CLINICS Fair SPACE FACILITY Data sorted by district, average condition of the facilities, and4 60 -80total space score Good SCORE

to select clinics that are in very poor condition for possible5 replacement.>80 Very good Space

ec Oliver Tambo ec Nyandeni Health Isilimela District 20.0% 80.0% 100.0% 80.0% 20.0% 20.0% 20.0% 20.0% 20.0% 80.0% 20.0% 20.0% 20.0% 20.0% 100.0% 0.0% 50.0% 20% 3 12 426 sub-District Gateway Clinic Municipality ec Oliver Tambo ec Mhlontlo Health Nessie Knight District 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 50.0% 100.0% 75.0% 20% 4 #N/A sub-District Clinic Municipality ec Oliver Tambo ec Qaukeni Health District Flagstaff Clinic 20.0% 52.0% 80.0% 60.0% 20.0% 20.0% 20.0% 74.0% 20.0% 52.0% 50.0% 20.0% 20.0% 20.0% 0.0% 0.0% 0.0% 26% 1 #N/A sub-District Municipality ec Oliver Tambo ec Nyandeni Health District Cwele Clinic 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 50.0% 40.0% 0.0% 0.0% 0.0% 33% 1 2 152 sub-District Municipality ec Oliver Tambo ec King Sabata District Dalindyebo Health Tyelebana Clinic 20.0% 0.0% 100.0% 80.0% 20.0% 40.0% 0.0% 20.0% 20.0% 0.0% 40.0% 0.0% 70.0% 0.0% 50.0% 0.0% 25.0% 34% 2 33 154 Municipality sub-District ec Oliver Tambo ec Qaukeni Health District Magwa Clinic 60.0% 68.0% 72.0% 62.0% 50.0% 48.0% 56.0% 52.0% 0.0% 68.0% 56.0% 70.0% 36.0% 58.0% 100.0% 100.0% 100.0% 40% 5 49 383 sub-District Municipality ec Oliver Tambo ec Mhlontlo Health Lotana District Lotana Clinic 40.0% 60.0% 40.0% 32.0% 60.0% 40.0% 44.0% 60.0% 0.0% 0.0% 0.0% 43% 1 9 410 sub-District Clinic Municipality ec Oliver Tambo ec Nyandeni Health Bambisana PHC Bambisana District 40.0% 40.0% 60.0% 60.0% 40.0% 60.0% 60.0% 60.0% 40.0% 40.0% 40.0% 60.0% 0.0% 0.0% 0.0% 44% 1 6 537 sub-District Clinic Hospital Municipality

ec Oliver Tambo ec Nyandeni Health Mtambalala District 40.0% 20.0% 20.0% 20.0% 54.0% 46.0% 20.0% 72.0% 56.0% 20.0% 26.0% 46.0% 50.0% 46.0% 50.0% 0.0% 25.0% 45% 2 3 902 sub-District Clinic Municipality

ec Oliver Tambo ec Mhlontlo Health District St Lucy's Clinic 40.0% 20.0% 60.0% 40.0% 48.0% 40.0% 20.0% 40.0% 44.0% 20.0% 60.0% 60.0% 36.0% 60.0% 100.0% 100.0% 100.0% 46% 5 5 068 sub-District Municipality ec Oliver Tambo ec Nyandeni Health Canzibe District 20.0% 80.0% 80.0% 80.0% 60.0% 60.0% 60.0% 60.0% 20.0% 80.0% 68.0% 40.0% 72.0% 40.0% 0.0% 0.0% 0.0% 48% 1 22 484 sub-District Gateway Clinic Municipality ec Oliver Tambo ec Mhlontlo Health Sidwadweni District 40.0% 80.0% 80.0% 60.0% 60.0% 40.0% 20.0% 70.0% 40.0% 80.0% 50.0% 20.0% 60.0% 20.0% 50.0% 100.0% 75.0% 50% 4 2 437 sub-District Clinic Municipality ec Oliver Tambo ec Nyandeni Health Nkanga District Nkanga Clinic 50.0% 40.0% 80.0% 80.0% 48.0% 40.0% 20.0% 50.0% 60.0% 40.0% 40.0% 20.0% 60.0% 20.0% 0.0% 100.0% 50.0% 52% 3 16 309 sub-District Clinic Municipality

ec Oliver Tambo ec Nyandeni Health District Bomvini Clinic 60.0% 20.0% 60.0% 60.0% 60.0% 20.0% 20.0% 20.0% 52.0% 20.0% 40.0% 20.0% 50.0% 20.0% 100.0% 100.0% 100.0% 52% 5 0 sub-District Municipality

ec Oliver Tambo ec Nyandeni Health St Barnabas District 60.0% 80.0% 80.0% 64.0% 50.0% 48.0% 80.0% 60.0% 60.0% 80.0% 50.0% 60.0% 50.0% 60.0% 50.0% 100.0% 75.0% 54% 4 16 848 sub-District Gateway Clinic Municipality ec Oliver Tambo ec King Sabata Zitulele District Dalindyebo Health 60.0% 40.0% 20.0% 20.0% 20.0% 60.0% 60.0% 40.0% 60.0% 40.0% 0.0% 0.0% 0.0% 55% 1 0 Gateway Clinic Municipality sub-District

ec Oliver Tambo ec Qaukeni Health 48 District Malangeni Clinic 52.0% 20.0% 20.0% 20.0% 46.0% 20.0% 20.0% 60.0% 52.0% 20.0% 66.0% 20.0% 60.0% 20.0% 50.0% 0.0% 25.0% 55% 2 188 828 sub-District Municipality BUT HOW DID WE ARRIVE HERE

49 PRIVATE SECTOR

50 The private hospital market in metropolitan areas (50%+ of medical scheme population) was concentrated by 1999..

100.0% 90.0% 80.0% 70.0% 60.0% Market 50.0% 40.0% becomes 30.0% concentrated 20.0% 10.0% Percentage of total acute beds acute total of Percentage 0.0% 1996 1998 2000 2002 2004 2006

Life Medi-Clinic Netcare Independent

Only 12.3% of private hospital beds were outside three main hospital groups by 2006… 51 Private hospital real cost trends (2009 prices)

350.0 Coincides with market ? 300.0 concentration

250.0

200.0

150.0

100.0

Real per capita expenditure capita per Real 50.0

0.0

2005 2006 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2007 2008 2009

52 …hospitals demonstrated a large growth in their return on investment…

Cost of debt Return on Investment

53 Competition Commission Ruling (2004)

1. Price negotiation as price fixing 2. Health as market commodity 3. Patient supposed to negotiate directly with their doctors 4. Minister of Health supposed to be a neutral arbiter

54 WHERE IS THE MONEY GOING TO

55 Medical Schemes Expenditure in 2010 • Total medical scheme spend on health – R84.7bn • Hospitals – R31.1bn, private R30.8bn (10%), public R281 (2.6%). • Specialists - R19bn • Medicines - R14bn (5.6%) • GPs - R6.2bn (9%) • Dentist - R2.5bn (13.2%) • Allied - R6.7bn (11.5%) • Total non healthcare- R11.6bn (6.9%)

56 57 ...but Discovery still has very high non-health costs...

2,500,000 140 117 114 107 120 2,000,000 105 103 99 97 96 96 100

1,500,000 80

1,000,000 Administration fees should be 60 Beneficiaries low in large schemes 36 40 500,000

20 Per capita expenditure (monthly) expenditure capita Per

0 0

GEMS

Liberty

Hosmed

Bestmed

Medihelp

Discovery

Keyhealth

Fedhealth

Resolution Average open schemes Average Average beneficiaries Administration Expenditure (pabpm) 58 …broker fees increased sharply up to 2005 but has declined slightly since then…

200

180

160

140

120

100 800% increase in five years

pabpa (R)pabpa 80

- 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 59 CMS Annual Report 2010 - 2011 CONSEQUENCES TO MEDICAL SCHEMES

60 Premium Increase

• For the past decade and a half, premiums have been increasing at more than CPIX • Benefits dropping at a very fast pace • Even measures such as PMBs worsened the situation • Workers demanding higher medical aid subsidies in a failed endeavour to stem the situation

61 Trend in the number of schemes

140 131 124 122 119 120 110 100 97 93 100 87 84 83 81 82 83 77 73 80 71 68 63 60 60 47 41 41 37 40 33 Number of schemes Number of 27 26 25 24 23 20

0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Open schemes Restricted schemes All

Consolidation: Small-sized restricted schemes 144 Schemes in 2000

62 GLOBAL TRENDS IN HEALTH CARE FINANCING

63 WHAT IS HAPPENING GLOBALLY?

100%

90%

80%

70%

60%

50%

40%

30%

20% Percent of total health care expenditure care health total of Percent

10%

Mandatory pre-payment Voluntary pre-payment Out-of-pocket

WHO National Health Accounts dataset (2009 data) 64 Africa – Disaster in the making

65 SOUTH AFRICA IS THE ODD ONE

South Africa is an outlier: world’s largest share of spending from VHI

68 Source: WHO estimates for 2012, countries with population > 600,000 World Health Report of the WHO

• The 2008 World Health Report of the WHO details three trends that undermine the improvement of health outcomes globally, namely: – Hospital centrism, which has a strong curative focus – Fragmentation in approach which may be related to programmes or service delivery – Uncontrolled commercialism which undermines principles of health as a public good

69 Solutions

70 Format of the White Paper on NHI

1. White Paper consists of 10 Chapters with 433 paragraphs /sections (as in sections in a legislation) 2. A set of Annexures designed to respond to the National Planning Commission’s visions: “Furthermore, the NDP envisions that by 2030 there should have been a significant shift in equity, efficiency, effectiveness and quality of healthcare provision...... ”

These Annexures are: Annexure A: Ideal Clinic Realisation and Maintanance, PHC Package, District Hospital Service Package Patient Referral System Annexure B: Regional, Tertiary and Central Hospital Service Annexure C: Management and Governance of Public Sector Hospitals under NHI Annexure D: Pathology / Radiology and Emergency Medical Services under NHI

71 THE WHITE PAPER ON NHI

72 Way Forward Establishment of NHI Work-streams

Work Stream 1 • Establishment of the NHI Fund

Work Stream 2 • Design of NHI Service benefits

Work Stream 3 • Prepare for the purchaser-provider split

Work Stream 4 • Future role of medical schemes

• Completion of NHI Policy and Development of Work Stream 5 NHI Legislation

Work Stream 6 • Preparation of the District Health System

73 NHI Work-Streams (1)

1. Establishment of the NHI Fund 2. Design of NHI Service benefits

Lead: Lead: 1. Prof Diane McIntyre 1. Dr Yogan Pillay

Full-time Full-time 2. Dr Jane Doherty 2. Dr Jane Doherty 3. Mr Kuben Pillay 3. Dr Aquina Thulare Part-time Part-time 4. Dr Terence Carter 4. Professor Narnia Bohler-Muller 5. Professor Charles Hongoro 6. Prof Diane McIntyre 5. Dr Mark Blecher 7. Dr Filip Meheus 6. Ms Wendy Fanoe 8. Professor Karen Hoffman 7. Dr Joseph Kutzin (WHO) 9. Dr Kalipso Chalkidou (NICE-UK) 10.Mr. Moremi Nkosi 11. Dr Joseph Kutzin (WHO)

74 NHI Work-Streams (2)

3. Prepare for the purchaser-provider split 4. Future role of medical schemes

Lead: Lead: 1. Dr Anban Pillay 1. Mr Vishal Brijlal

Full-time Full-time 2. Mr Kuben Pillay 2. Mr Moremi Nkosi 3. Dr Thabiso Makola Part-time Part-time 3. Mr Thulani Matsebula 4. Professor Diane McIntyre 4. Dr Keith Shongwe 5. Dr John Ataguba 5. Dr Aquina Thulare 6. Mr Moremi Nkosi 6. Dr Humphrey Zokufa 7. Dr Joseph Kutzin (WHO) 6. Dr Joseph Kutzin (WHO)

75 NHI Work-Streams (3)

5. Completion of NHI Policy and Development of NHI Legislation 6. Preparation of the District Health System

Lead: Lead 1. Dr Aquina Thulare 1. Mr Ramphelane Morewane Full-time 2. Mr Moremi Nkosi Full-time 2. Dr Thabiso Makola Part-Time 3. Professor Diane McIntyre Part-time 4. Dr John Ataguba 5. Professor Narnia Bohler-Muller 3. Professor Jannie Hugo 6. Professor Charles Hongoro 4. Dr Yogan Pillay 7. Dr Joseph Kutzin (WHO) 5. Ms Jeanette Hunter

76 THANK YOU