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Health Systems
Republic of South Africa
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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.
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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
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• 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
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Major
metropolita
n
areas
Provincial structures
at regional
level
9 provinces
Cape Town
Port Elizabeth
Durban
Johannesburg34% GDP34% GDP
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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
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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
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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
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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
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Positives and Negatives of the
Public/private debate
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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%
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8.5%
Health Care ExpenditureHealth Care Expenditure
Expenditure as a percentage of GDP
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7 million
37 million
Population covered: Private vs. Public
Private sector
Public sector
Health Care ExpenditureHealth Care Expenditure
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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”
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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
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• 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
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• 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
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• 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
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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
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Challenges for Private SectorChallenges for Private Sector
• Cost escalation• Consumer resistance• Low growth of formal
employment• Legislative environment• Accessibility• Affordability
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“…. 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.”