This opinion piece by Lydia Cairncross, Louis Reynolds, Russell Rensburg & Leslie London was published in the Daily Maverick on 22 April.
As we approach the probable end of the lockdown in its current form, epidemiologists and public health experts are looking at the experience from other countries for clues to how the Covid-19 pandemic may play out in our own unique conditions.
Exactly what will happen in South Africa as the pandemic progresses is uncertain. Whether we will have a peak in July or in September; whether lockdown has suppressed community transmission effectively or not; whether a slow return to normal will result in a resurgence and undo the work of the lockdown; or whether we have won some ground in controlling this epidemic. It’s all very much up in the air.
One thing is clear: any Covid-19 strategy will require a strong, coordinated and integrated health service at its centre. One that can move swiftly and effectively to manage the unfolding curve of the epidemic. At a societal level, Covid-19 can spiral us deeper into fragmentation and individualism, but it can also spark a growing spirit of collective action, social solidarity and a fresh clarity about the sustainability of our unequal society. The question is whether this moment can give impetus to building the health system we so desperately need.
We commend our Minister of Health, Dr Zweli Mkhize, for his bold and resolute leadership up to now. However, any health service plan needs to acknowledge that our current health service is fragmented between the public and private sectors, deeply inequitable and highly inefficient. It will be further weakened by Covid-19.
We urge Mkhize to do everything in his power to bring the public and private health sectors together as one coordinated and centrally managed health service under the National Department of Health (NDOH). The department will need technical and moral support from health experts from all sectors including academic, private and public system leaders in this area.
This strategic approach is supported by the recent World Health Organisation (WHO) Strategy Update of 14 April which says, “Governments must also re-purpose and engage all available public, community and private sector capacity to rapidly scale up the public health system.”
We have seen other countries’ examples of how the public-private health systems can work together during this time. These have included complete public administration of the private sector as seen in Spain and Ireland, contrasted against a country like the UK where the NHS contracts ICU beds from the private sector at exorbitant daily rates.
If we take a similar approach to the latter strategy and see this as the private sector “assisting” the public sector when it becomes overwhelmed, we potentially have a nightmare scenario where we wait for public hospitals to fill up and then “rent” high care and ICU beds from private hospitals at rates agreed to in desperation. The result could then be a bankrupt public health sector, leaving a private health system relatively intact and with some components even profiting from the pandemic.
Standardised protocols across both sectors
National stewardship of health resources is critical – at a practical level this means an integrated plan developed between public and private facilities at provincial and, possibly more importantly, at district level. These integrated facility plans should include agreement on uniform admission criteria to hospitals, with decisions regarding where patients are admitted being based on public health and infectious disease principles rather than medical scheme membership. This will prevent, for example, unnecessary transportation of patients between facilities, exposing a line of emergency and casualty health workers in the process.
Critical care beds in South Africa are a scarce resource with approximately 60% of the 3,200 ventilated beds currently available being within the private sector. An integrated public-private response will require uniform criteria and protocols for ventilation of Covid-19 patients.
At present, there are vast differences in the criteria used for ICU admission and ventilation between public and private facilities, with triage and rationing a standard part of public sector ICU admission protocols and private sector admission dependent on medical insurance coverage. It would be unacceptable for access to ventilation to be linked to medical scheme membership rather than on standard protocols and sound clinical criteria.
Similarly, uniformity in protocols and standards are necessary for Infection Control Plans, Occupational Health and Safety (OHS) and Personal Protective Equipment (PPE) protocols. Differing OHS and PPE standards between private and public hospitals would not only be incorrect on the basis of principle and equity, but also because a breach in infection control in a private or public facility can rapidly affect healthcare workers in other facilities due to the high proportion of doctors and nurses who work in both sectors.
An equitable approach to private hospital remuneration
We call for transparency on all contracts and arrangements made between the private sector and the NDOH. It is not clear at present what, if any, arrangements have been made, yet this is a matter of public interest and should be open to scrutiny. Working from the principle of pooling resources during the pandemic, patients should be admitted to private hospitals regardless of their medical scheme status.
An upfront agreement should be reached between the NDOH and private hospitals for a flat rate for general and ICU admission, benchmarked at public sector rates. Recent work on Disease Specific Groups (DRGs) done for the NHI should assist in this costing analysis. Importantly, current pricing using itemised billing at inflated private sector rates should not be permitted.
There should be no profit-making during this crisis.
A levy on medical scheme administrators to support the NDOH
Medical schemes which provide health coverage to approximately 15% the population are currently experiencing a massive decrease in claims due to the de-escalation of non-urgent and elective medical services in the private sector. While medical schemes are technically non-profit organisations, medical scheme administrators are not, and these are important role players in the private healthcare industry.
One way in which medical schemes could contribute to the resource pool would be through payment of agreed rates for public sector patients who are treated in private facilities. However, this is likely to be logistically challenging. The option of a levy on medical scheme administrators and/or medical schemes with large reserves, is a more practical solution.
As the NDOH can expect a massive increase in expenditure during this pandemic (including expenditure on PPE, payments for private hospital beds at public sector rates and increased employment of additional healthcare workers) this levy could serve as an immediate cash injection into the NDOH response and help to equalise the financial burden experienced by the entire health system during this time.
The NHLS and private laboratories
Mass screening and testing is a critical aspect of managing this pandemic. Success or failure in this area may be the making or breaking of containment for South Africa.
We need collaboration between all laboratory services to ensure adequate supplies of reagents and testing kits in all communities, taking into consideration the current concentration of these resources in urban and middle class areas.
The cost of a Covid-19 test needs to be agreed to at a national level, calculated at current cost without profit margin, and be standardised across all laboratories.
Testing must be provided to all who meet the criteria, either through NHLS or a private laboratory, regardless of medical scheme membership, with an upfront arrangement for payment from either medical scheme reserves or the NHLS. As testing numbers increase, private laboratories should agree to a quota percentage of free “pro bono” tests done for public sector patients as part of their contribution to the pooling of resources.
The role of healthcare workers
Most of South Africa’s healthcare workers currently work in the private sector. The reasons for this include the underlying drivers of privatisation of health in South Africa, including the deliberate contraction of the public health system during two decades of austerity budgets.
Healthcare workers have left the public sector for many reasons, including untenable working conditions, frozen posts or lack of public sector posts, lack of functional equipment and lack of career progression and support in rural areas, to name a few. While remuneration is often seen as a major driver into the private sector, this is only one part of a much more complex push-and-pull dynamic.
If the Covid-19 pandemic unfolds in SA as it has in countries like Italy, France and the USA, it will require all our healthcare workers to be drawn into a collective national response. This, we believe, is what most healthcare workers are expecting to do and are prepared to do.
We have all trained in the corridors of our public hospitals and learnt our craft and skill among the most vulnerable and marginalised in our society. We have all been frustrated and exploited by health bureaucracies and medical schemes. We hope that in this time, the NDOH will call on health workers from the private sector to join in the response to Covid-19. Those that can do this work voluntarily should do so, but for those who have lost their income – as many private doctors, specialists and allied healthcare workers have – remuneration at public sector rates should be arranged.
This process may over time result in a much-needed redistribution of healthcare workers from private to public.
In conclusion, planning the health system response to Covid-19 in South Africa requires a transparent, just and pro-equity public-private integration plan. In principle, this collaboration should be based on the public stewardship of pooled resources, standardised protocols across both sectors and a vision of building a strong, unified national health service.
As this plan is urgently required, we call for the creation of a sub-committee to the Ministerial Advisory Committee on Covid-19 to focus specifically on the public-private interface. Such a committee should include health economists, representatives of healthcare workers in the private and public sectors, leadership from the NDOH and private industry and representatives of civil society health movements. The work and comosition of this committee must be transparent and open to public comment.
In this way we can collectively navigate our way through the pandemic, bringing our health systems together not only to manage this emergency, but also to lay the foundation for a future health service based on equity and social solidarity. DM/MC
Lydia Cairncross is a public sector doctor and member of the People’s Health Movement of SA (PHMSA); Louis Reynolds is a paediatric intensivist and member of the PHMSA; Russell Rensburg is the Director of the Rural Health Advocacy Project (RHAP); Leslie London is a specialist in public health medicine and member of the PHMSA.
This article is endorsed by the C19 People’s Coalition Health Working Group. The C-19 People’s Coalition is a coalition of over 250 organisations campaigning for a just and equitable response to Covid-19 that meets the needs of the most marginalised in South Africa.