Elaine McKay Head: HIV Strategy

1. Presentation to Global Campaign for Microbicides Consultation:Insurance Funds as options to operationalise access to ART 19 – 20 June 2008 Elaine McKay Head: HIV Strategy

2. Agenda 1. Introducing Medical Schemes and Discovery 2. HIV and AIDS in Discovery Health 3. The HIV Partnership Fund and others

3. What is a “medical scheme” (South Africa) • A medical scheme helps you to pay for your healthcare needs, such as nursing, surgery, dental work, medicine and hospital costs. • It can be described as “insurance” you are taking out to cover your health costs. You (and in certain cases your employer) pay regular contributions to the scheme. • A medical scheme is a non-profit organisation and should be registered at the Registrar of Medical Schemes. A board of trustees who are elected by the schemes’ members manages a medical scheme. They are responsible to manage the scheme to the benefit of its members. • The Medical Schemes Act (No 131 of 1998) came into effect on 1 January 2001. • Offers a compulsory minimum package of benefits and exclusion of risk rating, and the discrimination on the basis of health, age, race, gender of medical history (important in the context of what would be termed “anti-selection” for trial participants

4. What are the advantages of belonging to a medical scheme • You have the security of knowing your medical needs will be looked after • A portion of your contribution can be deducted from your taxable income • You can budget for your medical expenses • You can get the best medical care available in facilities with state of the art equipment and infrastructure • You can undergo medical surgery when you need it most and not be put on a waiting list for available doctors to perform the surgery or availability as in the case of state hospitals • You will be treated immediately in the case of an emergency without any worries regarding funds available • You can benefit on a personal level with different wellness and vitality options available

5. What should a medical scheme pay for? • In 2004 the Medical Schemes Act of 131 of 1998 introduced Prescribed Minimum Benefits (PMB). • It is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. • The aim is to provide people with continuous care to improve their health and to make healthcare more affordable. • PMBs determine that medical schemes have to cover the costs related to the certain diagnosis, treatment and care of medical conditions. Important since HIV and AIDS are covered under PMBs

6. The Discovery Group 2 million lives 1.2 million lives 250,000 lives 172,053 policies 59,262 lives 89,220 lives Driven by a central mission Statement: To make people healthier and enhance and protect their lives

7. 2 million lives Feb 2007 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Growth in lives under management 2,000,000 • Established in 1992 • Covering 1 open scheme and 11 Restricted schemes • R19 billion in premium income per annum 1,500,000 Lives administered 1,000,000 500,000 0

8. 100 Discovery 80 60 Next top 15 open schemes in SA 40 Change in membership ('000) FedHealth Oxygen 20 Spectramed Hosmed Resolution Medicover BestMe Liberty Munimed Sizwe MediHelp ProSano Medshield Bonitas 100 200 300 400 500 600 700 800 Momentum -20 Membership level end 2005 ('000) -40 Unique position in market Source: 2006 Global Credit Rating reports and scheme financial results Discovery is positioned at the centre of the healthcare system

9. Claims New business • 120,000 claims per day • 96% claims within 3 days • R 7,000,000 paid per hour • 85% paid directly to health professionals • Process 1,000 – 1,500 new lives daily • 80% processed in less than 2 days Service to members Interaction with health professionals • 1 patient hospitalised every 56 seconds • 35,000 calls answered per day • Answer 90% within 20 seconds • 92% of calls resolved on first contact • R19bn billed annually • 14,588 GP consultations paid per day • 4,383 Specialist consultations paid every day Integrated scalable systems provide world class support to Discovery

10. 80,000 12,560 8,937 6,181 3,940 Estimated prevalence HIV and AIDS in Discovery Health Medical Scheme Number of members registered on disease management versusestimatedprevalence 90,000 80,000 70,000 60,000 50,000 Members 40,000 30,000 20,000 10,000 0 2004 2005 2006 2008 (To date) 70% of enrollees require ART at registration

11. HIV (-ve) HIV (+ve) DHMS or other medical scheme members Uninsured Prevention Identify funding source Enroll on HIV disease management programme HIV Strategy in the Workplace VCT for all Employees

12. Public facilities • NGO/Bilateral donor funded programmes such as Right to Care, BroadReach • Direct corporate funding (AngloAmerican, SAB Miller etc) HIV Insurance Models Funding Options for HIV+ uninsured employees and their family members

13. Insurance for Health Service Delivery in the context of HIV

14. Important issues to consider • Reciprocity vs justice • Anti-selection (few who seroconvert) vs equity (all participants) • ART for few or better health care for all (responsibility to community) • Don’t have to do it alone • Vaccine Initiative • PharmAccess and Health Insurance Fund • Civil Society • donors • Opportunity to be innovative and demonstrate impact in a complex trial environment

15. Options for Trial Participants • Registration of/with a Fund (preferably in country) which: • are based on risk pooling and thus realise solidarity : offer subsidised contributions from donors • protect against unexpected financial shocks due to illness • generate budgets for investments in efficient health care, and • empower members to insist on high quality health care. • Funds would cover the costs of case management, of out-of-hospital treatment, including ARV medication (basket of services) where clinically indicated, monitoring tests (CD4/VL) etc. • Supports the development of better health care facilities where these do not exist (clinic improvement initiatives, better training of doctors and nurses etc.) – leverage current “health systems strengthening agenda • Could be joint IAVI/IPM Fund with other partners (e.g. donors)

16. Other Options • Work with an existing medical insurer to design a product for trial participants • Efficiency and effectiveness would be determined by number of beneficiaries (closed scheme) – issue of who is the employer? • Expensive option since risk pool would have to be funded upfront • Simpler to manage since administrator would take responsibility for payment of claims etc. (outsource arrangement) • Purchase disability cover for participants (scope for misuse of funds since money is paid to beneficiary not service provider) • Recommendations: • Push current boundaries and limitations; explore new and innovative partnerships.