Health Systems

Republic of South Africa

South Africa in Relation to AfricaThe RSA occupies the southern most part of the African Continent, with a surface area of 1,220km². Population of +46 Million people.

Understanding South Africa

Growth rate

Inflation

National debt

Unemployment

GDP

Exports

Imports

3.6 - 4%

4-6%

37% of GDP

30-40%

$472 billion

45.2billion

32.6 billion

• Powerhouse of Africa• GDP is 25% of the GDP of Africa• Leader in Industrial output (40% of

Africa's output)• Generates half of Africa’s electricity

• Bustling informal economy– Unmeasured– Unregulated– Untapped potential

Source:,www.sainfo.com

• Natural minerals & metals

• Growing manufacturing sector

• Strong service industry

• Growing potential tourism industry

• Magnificent natural beauty

45%

25%

30%

service

industry

agriculture

Source:,www.sainfo.com

Major

metropolita

n

areas

Provincial structures

at regional

level

9 provinces

Cape Town

Port Elizabeth

Durban

Johannesburg34% GDP34% GDP

Health Authorities

•Public EntitiesNational Department of Health

Provincial Health Department

Primary Health/Community Health

•Private EntitiesPrivate hospital groups and clinics

Specialists

Nurses

Pharmacists

Allied Health Workers

Other Influential Role Players

•Statutory Bodies (HPCSA; MCC)

•NGO/Donor agencies

– involved in a range of health promotion and prevention projects

•Lobby groups/Unions (TAC; COSATU)

•Defense special health care facilities

•Mines special health care facilities

Process Flow for an insured Individual

LOW RISK Health individuals

Apathetic &

Nostalgic 65%

Diseased 20% AV

E. W

OR

KF

OR

CE

C

ON

TIN

UU

M

HIGH RISK

HEALTH SERVICES CONSUMPTION OF EMPLOYEES NOT IN MEDICAL SCHEME *

* Large number will become covered with advent of SHI

State Clinics

Dentists

Pharmacies

Optometrists

State Hospitals (specialists)

GPS/Dispensing Doctors

HIV/AIDS Program

Represents health risk management value chain – covered by scheme system

Represents Employer-based health risk interventions for all or some employees

Represents health risk management value chain for MB/Basic benefits– uncovered outside scheme system

Real T

ime

Inte

rfacin

g

•MC Program info

•Claims info

•Benefit Info

•PMB Protocols

Specialist Network

HIV/AIDS Program

Choice of Service provider -Health Incentives/rewards

RISK ID

Hospital Benefit mgt

Disease Management

ADMIN & MC SYSTEM

GP Network

Pharmacy Network

Oncology

Medicine Mgt

PMB Mgmt

Maternity

Hospital Network

Optometrist Network

Dentist Network

HEALTH RISK MANAGEMENT FOR %

OF WORKFORCE IN MEDICAL SCHEME

EMPLOYER LEVEL INTERVENTIONS TO MANAGE HEALTH RISK WHICH MAY APPLY TO COVEREDS AND UN-COVEREDS

WorkplaceClinics OCC

Health

EAP AbsenteeismManagement

Education Executive Health

Process flow for an un-insured individual

No risk assessment

Available Choices ofService Provider

Public Primary Health Care facility

Will fully fund any Drugs from the Pharmacy

Referral to a Provincial or Tertiary Public establishment

Traditional Healer

Herbal Medicine

Traditional Networks and Referral system within the

Community

Unwell individual

PoorFinancially Affording

Will pay cash for Private Health Care facilities

Positives and Negatives of the

Public/private debate

Healthcare Costs

The inter-related challenges impacting on healthcare costs and affordability

Employers moving away from post-Retirement financing – need for pensioners to self-manage

Lack of adequete outcomes reporting to show the value add of MHC (PMB/DRM)

Growing concern amongst employers as to whether tools used to control costs to date (managed care, benefit design/re-structure) are working to extent it was hoped

Cost-shiftingfrom employer to employee

Provision of low cost healthcaredelivery to enableaffordable productsand access for emergingmarket

Move to Social Health Insurance – more employees on scheme benefits and greater employer subsidy

4.82 Million people living with Aids

Prevalence rate of 26.5%

8.5%

Health Care ExpenditureHealth Care Expenditure

Expenditure as a percentage of GDP

7 million

37 million

Population covered: Private vs. Public

Private sector

Public sector

Health Care ExpenditureHealth Care Expenditure

7 million

37 million

Relative expenditure split

Private sector

Public sector

R 59 billion / 58%

R 43 billion / 42%

Health Care ExpenditureHealth Care Expenditure

“Chronic inefficiency of distribution”

Wellness of the nationWellness of the nation

• WHO rates South African Health care delivery as 175 out of 191 nations

Key factors affecting health outcomes

• WHO rates South African Health care delivery as 175 out of 191 nations

• Key factors affecting health outcomes– Violence

Total deaths PA in 100 000 lives

RSA USA

89

9

Wellness of the nationWellness of the nation

• WHO rates South African Health care delivery as 175 out of 191 nations

• Key factors affecting health outcomes– Violence– Socio-economic circumstances

• Poverty

Infectious diseases

• Tuberculosis

• HIV and Aids

• Malaria

• STD’s

Percentage TB cases that are HIV positive

25%

Wellness of the nationWellness of the nation

• WHO rates South African Health care delivery as 175 out of 191 nations

• Key factors affecting health outcomes– Violence– Socio-economic circumstances

• Poverty

• Lifestyle

Chronic diseases

• Diabetes• Asthma/COPD • Cardiovascular (CVD)• Obesity• Metabolic syndrome

Wellness of the nationWellness of the nation

Medical Scheme Benefits -Medical Scheme Benefits -

• Prescribed Minimum Benefits – over 250 conditions

• Chronic disease cover– Covers 25 most common Chronic

Conditions– Also covers HIV/AIDS

• Other benefits– Dentistry– Optical– Out of hospital radiology and pathology

Challenges for Private SectorChallenges for Private Sector

• Cost escalation• Consumer resistance• Low growth of formal

employment• Legislative environment• Accessibility• Affordability

“…. The ultimate challenge to the system will be a collective ability

to

“Ensure access and long term financial sustainability in the provision of quality

health care for the South African people.”