Health Systems

1. Health Systems Republic of South Africa

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

3. 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 • Bustling informal economy • Unmeasured • Unregulated • Untapped potential • 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 Understanding South Africa Source:,www.sainfo.com

4. agriculture 30% 45% 25% industry service • Natural minerals & metals • Growing manufacturing sector • Strong service industry • Growing potential tourism industry • Magnificent natural beauty Source:,www.sainfo.com

5. Johannesburg Provincial structures at regional level 9 provinces Durban Port Elizabeth Major metropolitan areas Cape Town 34% GDP

6. Public Entities • National Department of Health • Provincial Health Department • Primary Health/Community Health • Private Entities • Private hospital groups and clinics • Specialists • Nurses • Pharmacists • Allied Health Workers Health Authorities

7. 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

8. Process Flow for an insured Individual EMPLOYER LEVEL INTERVENTIONS TO MANAGE HEALTH RISK WHICH MAY APPLY TO COVEREDS AND UN-COVEREDS HEALTH SERVICES CONSUMPTION OF EMPLOYEES NOT IN MEDICAL SCHEME * HEALTH RISK MANAGEMENT FOR % OF WORKFORCE IN MEDICAL SCHEME * Large number will become covered with advent of SHI WorkplaceClinics EAP AbsenteeismManagement OCC Health Education Executive Health LOW RISK GP Network Pharmacy Network Choice of Service provider -Health Incentives/rewards Health individuals State Clinics AVE. WORKFORCE CONTINUUM Apathetic & Nostalgic 65% GPS/Dispensing Doctors RISK ID ADMIN & MC SYSTEM • MC Program info • Claims info • Benefit Info • PMB Protocols Real Time Interfacing HIGH RISK Diseased 20% Pharmacies State Hospitals (specialists) Hospital Network Dentists Specialist Network Optometrists Dentist Network Disease Management Hospital Benefit mgt PMB Mgmt HIV/AIDS Program HIV/AIDS Program Medicine Mgt Optometrist Network Maternity Oncology 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

9. Process flow for an un-insured individual No risk assessment Financially Affording Poor Unwell individual Available Choices of Service Provider Will pay cash for Private Health Care facilities Traditional Healer Public Primary Health Care facility Herbal Medicine Will fully fund any Drugs from the Pharmacy Traditional Networks and Referral system within the Community Referral to a Provincial or Tertiary Public establishment

10. Positives and Negatives of the Public/private debate

11. The inter-related challenges impacting on healthcare costs and affordability Employers moving away from post-Retirement financing – need for pensioners to self-manage 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% Healthcare Costs Provision of low cost healthcaredelivery to enableaffordable productsand access for emergingmarket 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

12. Health Care Expenditure Expenditure as a percentage of GDP 8.5%

13. Health Care Expenditure Population covered: Private vs. Public Private sector 7 million 37 million Public sector

14. Health Care Expenditure R 59 billion / 58% Relative expenditure split Private sector 7 million 37 million Public sector “Chronic inefficiency of distribution” R 43 billion / 42%

15. WHO rates South African Health care delivery as 175 out of 191 nations Key factors affecting health outcomes Wellness of the nation

16. 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 89 9 RSA USA Wellness of the nation

17. WHO rates South African Health care delivery as 175 out of 191 nations Key factors affecting health outcomes Violence Socio-economic circumstances Poverty Percentage TB cases that are HIV positive Infectious diseases 25% • Tuberculosis • HIV and Aids • Malaria • STD’s Wellness of the nation

18. WHO rates South African Health care delivery as 175 out of 191 nations Key factors affecting health outcomes Violence Socio-economic circumstances Poverty Lifestyle Wellness of the nation Chronic diseases • Diabetes • Asthma/COPD • Cardiovascular (CVD) • Obesity • Metabolic syndrome

19. 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

20. Challenges for Private Sector • Cost escalation • Consumer resistance • Low growth of formal employment • Legislative environment • Accessibility • Affordability

21. “…. 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.”