Medical Chronicle November/December 2013 | Page 12

specialists as they graduate,” said Crisp. “So I question the
point of investing in training more specialists simply in order to
export them - we need to look at absorption capacity.”
Professor Bongani Mayosi, Head of the Department of
Medicine at Groote Schuur Hospital, countered there was
enough existing capacity to train many more specialists, the
problem was that it was underutilised. “The real priority is to
make use of what we already have. We produce around 600
specialists a year, but no one is coming to ?nd them to employ
them and as a result they often drift – and drift overseas.”
Executive of Government and Stakeholder Relations at
Mediclinic, Dr Nkaki Matlala said partnerships between the
public and private sectors could help increase the number of
specialists trained. “We need a Marshall Plan to address the
shortage of specialists.” Matlala pointed to private hospitals’
contributions to the Public Health Enhancement Fund, which
helped fund 100 more students to go to medical school in
2012. “For many years the private sector has provided material
support, but we would like to provide more – especially
intellectual capital and expertise.”
INDIA’S HIGHLY COMPETITIVE HEALTHCARE SECTOR
OFFERS SOUTH AFRICA KEY LESSONS ON BROADENING
ACCESS
South Africa could learn much from India’s example in making
healthcare more easily available, said managing director
of India-based management consulting ?rm HealthBridge
Advisors, Dr Adheet Gogate. Gogate said Indian healthcare
players have innovated relentlessly, with the result that private
healthcare businesses are booming and more people than
ever are able to access quality healthcare at different price
points.
“Like South Africa, we have a situation where world-class
outcomes co-exist with nearly unavailable care,” said Gogate.
“About 60% of the country does not have reliable ambulance
services, and rehabilitation, step down and paramedical
care is largely absent, yet we have pockets of excellence. The
interesting thing is, these pockets are not necessarily at high
price points but exist at virtually all price points.”
Despite the challenges, India’s healthcare sector has grown
and has generally operated as an extraordinary free market.
“We have a competitive, diverse provider landscape, with
healthcare providers at every price point,” said Gogate. “You’ll
?nd premier hospitals and low cost players operating, often
in the same neighbourhood.” These providers offered a
variety of capabilities and innovative business models to keep
prices low: these innovations have a lot to teach to providers
in places like South Africa, which has similar challenges.
“India has shown that if enough people buy different types of
healthcare, the system can respond with exciting, compelling
solutions,” he said.
INNOVATION, TECHNOLOGY KEY TO EFFICIENCIES IN
PRIVATE HEALTHCARE
Extracting ef?ciencies and value in healthcare delivery is
a global challenge as countries confront rising medical
expenditure and critical health needs of populations,
according to Margaret Guerin-Calvert, founding director of
US-based consultancy, Compass Lexecon. Guerin-Calvert
told delegates that healthcare was an increasing burden
on governments, healthcare systems and employers.

value was an integrated delivery system.
PROVIDING POOR QUALITY HEALTHCARE CAN BE COSTLY
IN THE LONG-RUN
Poor quality of healthcare not only affected patients,
but was a major cost to healthcare systems generally,
according to healthcare quality expert, Dr David Munch,
Senior Vice President of US-based Healthcare Performance
Partners. Dr Munch said better quality care was often a
cost-saving measure. “Good quality, if done properly will
almost always cost less than poor quality,” said Dr Munch.
“If you accept that higher quality can cost less, emerging
markets with fewer resources will ?nd that it is imperative
that resources are not wasted on poor quality care.”
Dr Munch said poor quality was only pro?table if there was a
monopolistic situation in the healthcare system and there was
no consequence to providing poor quality. He added that in
the absence of data and transparency about performance,
it was easy for a healthcare provider to be thriving ?nancially
while providing poor quality care, but as more data became
available, ?nancial incentives became more aligned.
“It’s important to have robust measurements in place, allowing
healthcare institutions to predict o utcomes more effectively
as well as determine the causes of poor quality,” he said. “In
addition, measurements need to be made in many domains:
clinical quality, experience of care, as well as cost of care.”
INNOVATION COULD HELP IMPROVE THE WAY CANCER
PATIENTS ARE TREATED, SAYS EXPERT
South Africa’s healthcare system needs to use ‘disruptive
innovation’ to change the way it delivers healthcare to
patients, said executive manager at Independent Clinical
Oncology Network (ICON), Dr Martin de Villiers. De Villiers
said the country’s healthcare system was not purposefully
organised to deliver quality care to patients. “There has not
been any major innovation over the past 20 years and you’ll
still ?nd a fragmented system centered on specialist and
hospital care,” he added.
He used the example of a new approach to treating cancer
to demonstrate what was possible when innovative thinking
disrupted conventional ways of treating disease. In 2012,
schemes spent R8 billion on cancer-related treatments for
patients. “What is missing is that the patient is not at the centre of
how the healthcare system treats the disease,” said de Villiers.

public hospitals were not. They also faced different
production constraints, such as accounting for their
infrastructure and capital stock, accessing funding and
capital and different costs of borrowing. If a differentiated
price system were to be implemented, it would require
price adjustment and for prices to vary in line with the
in?uence of the unavoidable costs.
ACHIEVING UNIVERSAL HEALTHCARE FOR ALL IS
POSSIBLE IN SOUTH AFRICA NOW
CEO of Netcare Limited, Dr Richard Friedland, said a social
compact between the public and private sectors to create
an equal and effective healthcare system was essential
if universal coverage was to be achieved. “Ef?cient care
can be delivered within the public sector,” he said. “A
mixed model of delivery in terms of private and public
patients is already working effectively in the UK. It is time
to implement something similar in South Africa.”
He said this requires a different delivery model that
allows providers to manage the complete pathways
of care, as opposed to the fragmented, uncoordinated
manner in which primary, tertiary and follow-up care is
administered. Friedland pointed to the Queen ‘Mamahato
Memorial Hospital in Lesotho, where a 425 bed public
hospital and three primary care referral clinics, servicing
a population of over 1.8 million people is now managed
by the private sector.
Improvements in outcomes achieved after just one
year in operation of the new hospital showed a 41%
reduction in the death rate, a 21% reduction in maternal
mortality and a 65% reduction in the paediatric
pneumonia death rate. This was achieved despite the
number of in hospital admissions increasing by 51%
and outpatient visits increasing by 126% due to the
demand for services.

Prof Sam Mokgokong

Dr Ayanda Ntsaluba

Shivani Ramjee

Dr Adheet Gogate

Stavros Nicolaou

Brand Pretorius

Tembinkosi Bonakele

Anthony Norton

De Villiers said ICON began negotiating cancer-speci?c
bene?ts with medical schemes. This included simple steps,
such as not requiring patients to foot the bill for co-payments
at the point of service, and using bundled code sets to ensure
predictability of cost.
De Villiers said he hoped these learnings could be rolled out
for other diseases, such as HIV and mental health, which
pose signi?cant risk to schemes, but which aren’t always well
managed. It could also apply to chronic illnesses such as
hypertension, asthma or epilepsy.
FAIR REIMBURSEMENT OF HEALTHCARE PROVIDERS IS
KEY TO NHI SYSTEM WORKING

“In response (to this burden), innovative approaches are
developing to increase value – not just lower costs,” she
said. “These include new models of delivery, payment
and purchasing that align providers, employers, insurers,
governments and individuals around the patient care
continuum.” Reforms needed to engage a range of players
with efforts to develop capacity and investment in communitybased care and support.

Establishing a fair playing ?eld for reimbursing public and
private healthcare providers, such as hospitals, is key to
ensuring that the proposed National Health Insurance (NHI)
system would work ef?ciently. Director of the Economics
of Social and Health Care Research Unit at the Centre for
Health Economics University of York, Professor Andrew Street
said: “All providers should be subject to the same regulatory
and reporting arrangements. Failing which differentiated
prices could be more appropriate to encourage the entry
and participation of different providers and if providers were
delivering different services.”

“There is no one-size-?ts-all for achieving ef?ciency and value,”
she added. “Achieving meaningful ef?ciency requires more
than expenditure reduction.” She said the key to achieving

“Providers face different, unavoidable costs,” added Street.
For instance, regulatory factors affected private and public
hospitals differently – private hospitals were taxed, while