The Tshepang Trust is an attempt to forge a prototype partnership between GPs and public sector hospitals in order to provide care for HIV/AIDS patients. It was launched amid a perceived assault on the private sector, and the spectre of a public sector less and less able to cope with the demand for health care in South Africa.

Speaking out is hard to do, says Dr Kgosi Letlape, chair of the South African Medical Association, the body that represents the approximately 16 000 doctors in South Africa.

“Standing up for the truth in South Africa is considered to be unpatriotic, particularly when you are black. But the only thing I really own is my integrity,” he said at a briefing at the South African Institute of Race Relations (SAIRR) in February 2004.

Letlape has spoken out about many aspects of government’s health policy which he is convinced will have deleterious consequences for patients, policies which he believes are largely aimed at removing the private sector from the health system equation. “Of course there are good intentions on the part of government. But the road to hell is paved with good intentions.”

Letlape would have liked to see a health system develop in South Africa that would involve government contracting private health professionals to treat patients. But that plan fell by the wayside soon after 1994, and instead the emphasis was placed on government primary health clinics - which Letlape said was not misplaced, but should not have come at the cost of funding secondary and tertiary institutions.

The South Africa Human Development Report produced by the United Nations (the UN Report) seems to support Letlape’s contention: the UN Report found that by 2000, 40% of hospital infrastructure needed replacing or major repair. Their report points out that whilst maintenance expenditure is currently at 0.5% of total asset value, the recommended level to merely maintain existing infrastructure is 3% of total asset value.

This is while more than 900 clinics have been built or upgraded; and pregnant women and children under six years of age receive free health care. Yet average life expectancy in South Africa has dropped from 61.5 years in 1994 to below 50. By 2010, it is expected to slip to just under 40, according to the UN Report.

“The main problem in the public sector is gross under-funding. There is no real financial commitment from government We need R10bn capital expenditure to save public secondary (regional) and tertiary (teaching) institutions from collapse now.”

The Tshepang Trust

To show the way in which an alternative health management system might work, SAMA launched the Tshepang Trust, of which Letlape is Executive Director, in December 2003. The Tshepang Trust is a partnership between SAMA, the Nelson Mandela Foundation (which provided start-up funding) and the Western Cape provincial government. Together these entities will deliver anti-retrovirals to patients at the GF Jooste Hospital on the Cape Flats, while providing constant monitoring and care to their patients.

“With AIDS it is not simply a matter of writing out a repeat script for anti-retrovirals. Through the Trust, the patients will start their treatment at a public hospital, which will continue to provide the drugs, but which however cannot realistically provide the constant monitoring to check on side-effects, toxicities and effectiveness. The patient will then be assigned to a GP in private practice, who will provide these services to save the hospitals from overload and provide the patient with a personalised treatment and ensure compliance.”

The Trust eventually hopes to have two such public-private partnership sites in each province, which will provide optimal treatment to at least 9 000 patients, or 500 patients per site. The cost per patient per month will be around R750, including the cost of drugs, fees to service providers and laboratory tests. This proposal follows on SAMA’s recent calls to government and other organisations to make a concerted effort in treating people living with HIV/AIDS.

“Our aim with this project is to bring doctors and patients together by utilising existing infrastructure. Currently about 70% of general practitioners practise in the private sector, while 80% of the population depend on public health services. We believe that HIV/AIDS should be viewed from a therapeutic perspective as a chronic medical condition similar to hypertension and diabetes that can be managed by general practitioners. This will help to remove the stigma around AIDS. It is our intention to actively involve the academic sector and the provincial public health authorities in monitoring and evaluating the implementation of the project,” said Letlape when the project was first mooted in 2002.

Private Sector under Threat

The Tshepang Trust is an earnest attempt by SAMA to work with government and show the way to an alternative form of health care which makes optimum use of the private sector. Government’s attempts to end “apartheid in health care” seem, according to Letlape, to be aimed at curbing the private sector.

“Frankly, I believed there’s a plan to get rid of the private sector. It’s not being articulated as such but it’s rolling out as such,” Letlape said at the SAIRR briefing. “We were told by the [director-general of health] in August 2002 that [the health department's] philosophy [on HIV/AIDS] was very simple: ‘if you can’t treat everybody, you treat nobody’.”

Letlape believes the private sector is under pressure through National Health legislation, in terms of which, among other things, doctors will not be allowed to dispense medicines unless they obtain a certificate from government, which will not be issued if there are already sufficient pharmacies serving the area concerned. “A lot of elderly and indigent patients depend on GPs for package deals of R70, R100. You go around the world, you will not find a more cost-effective way of delivering health care.”

Should doctors not be given a certificate by government, their patients will have to go on to a pharmacy to get their prescriptions filled, which will involve greater costs for the patients and much more effort, especially for old and frail patients.

This provision on dispensing by doctors has to be seen in the context of recently implemented regulations on medicine pricing, launched with much fanfare in mid-2004 but now being battled in court. This legislation, according to pharmacists, threatens pharmacists’ livelihoods; government promised pharmacists they would make up for lost margins on medicine pricing by the increase in volume occasioned by putting an end to dispensing doctors where they were not needed (they would not be licensed because of the proximity of a pharmacy).

The medicine pricing regulations do away with all discounts in the medicines distribution system, and prohibit profit on the medicines themselves - only professional fees may be charged. Manufacturers can only charge a single exit price, which in future years will be determined by referring to a basket of international prices. The professional fee which retail pharmacies may charge for prescription drugs is set at 26% or a cap of R26. (Non-prescription medicines are capped at R16). The dispensing fee for dispensing doctors is set at 16% or a cap of R16.

The “one size fits all” pricing regulations may mean that it will only be financially viable to distribute to the major urban centres, which will be disastrous for patients in rural areas. Pharmacists may also fail to stock high-price medicines, as the margins will be too low to make it worthwhile. Dispensing doctors may be able to compensate for losses on medicines sales by putting up fees.

Pharmacists and dispensing doctors are now placed in opposition to each other, as the Department of Health appears to have backtracked on its plan not to licence dispensing doctors who operate close to pharmacies, and appears to be licensing all who apply. Pharmacists are not taking the regulations lying down; they shut their doors on 1 June 2004 for two hours in protest.

The Pharmaceutical Society of South Africa has launched a court challenge, saying that more than 1000 of the estimated 5200 retail pharmacies in the country will fail to survive as a result of the regulations - thereby reducing the overall availability of drugs. Bulk retailer Clicks, which recently spent hundreds of millions of Rand converting 80 shops into retail pharmacies, has joined in the challenge.

Leon Louw of the Free Market Foundation has suggested that the regulations are in fact ultra vires - he says the Medicines Act empowers the Minster to determine a “transparent pricing system” and to prescribe ways in which prices should be published - but nowhere is the Minister granted powers to impose regulations on price increases.

The medicine pricing regulations apply only to the private sector - the state already buys medicines at very low prices through the tender system. As much as 80% of medicines by volume are sold to the state, but this accounts for only 20% by value, because of the low state prices.

A further challenge to the private sector contained in the National Health legislation is the requirement that GPs and other health professionals obtain a “certificate of need” before they can establish their practice. This mechanism basically gives government the power to decide how many doctors work, and where they work, in the private sector. While the Minister of Health has indicated that existing practices will not require such a certificate, the legislation does not make this clear. “Everything rests on the Minister’s discretion,” says Letlape.

Public Sector Deteriorating

Yet while the private sector appears threatened and subject to increasing government control, the public sector appears less and less able to do the job of serving the health needs of the country.

Financial constraints have lead to the removal and freezing of posts in the public sector. This has deleterious consequences, as Letlape explains: “There is always a lot of movement at the provider level. A nurse will move up the ladder from being an assistant nurse to being a professional nurse with intensive care unit skills. A doctor will be a medical officer who becomes a registrar who then becomes a specialist. So there is a lot of movement … including movement outside the country … as people move, space is created.

“But then the posts are frozen. The policy is that all posts are frozen. A doctor who has qualified as a consultant will be kept in a medical officer post rather than being given a consultancy because the consultancy post above him is frozen. And so the next doctor leaves South Africa. By now, 80% of the ophthalmologists who qualified in the 1980s have left”. (Letlape is an ophthalmologist.)

Nurses are also leaving in droves. The Cape Times reported in early 2004 that late last year, the Health Ministry revealed that almost 31 000 nursing posts were not filled across the country. Gauteng had the greatest nursing shortage, with 7 976 posts unfilled, and the Western Cape had 2 533 vacancies. This was less than half the number of vacancies in KwaZulu-Natal, which had 6 098 empty posts, while the Free State is short of 4 234, according to the Cape Times.

The UN Report confirms that “in many hospitals and clinics around the country, there are insufficient medical and support staff to handle the workload. There are simply not enough funds being allocated to the hiring of additional staff and the payment of more attractive salaries.”

Consequently, service levels continue to deteriorate. Elective surgery is often postponed. Cataracts are blinding and disabling, but because they are not an emergency, operations are put off. People with colon cancer have had to wait six weeks for surgery, although time is of the essence in such cases. The same applies to women with breast cancer. Patients sometimes have to wait for two days in queues to be seen at all, says Letlape.

Indeed, anecdotes of deteriorating public sector conditions abound. The South Coast Herald reported in 2004 that there was so little room in the maternity wing of the Port Shepstone hospital that patients were forced to share beds or sleep on the floor, often having to use linen that was not properly washed. The Hospital in Umtata reports similar bed-sharing and dirty linen concerns.

News24 also in 2004 reported that The SA Human Rights Commission has expressed concern that hundreds of sick villagers are forced to queue for treatment at Limpopo’s notorious Tintswalo hospital from before dawn every day, but only a handful ever get medical assistance.

“There are queues everywhere - for admission, for treatment and even at the dispensary for medicine. People come here at 5am, but hundreds go home again at night without having been helped,” said SAHRC spokesperson George Masanabo. “Some of the queues have up to 500 people in them.” Tintswalo hospital serves the densely populated peri-urban Bushbuckridge, Acornhoek Thulamahashe and Dwarsloop regions, which are home to almost one million people.

As Letlape puts it: “The word “crisis” does not nearly describe the mess we are in … When the new government came in, we hoped for great strides forward. But now things are getting worse.”

The South African miracle based on compromise and tolerance may still play out in the health sector too - and the Tshepang Trust could be just the beginning.

DrKgosi Letlape has been in private practice as an ophthalmologist since 1989. He is chaiperson of the South African Medical Association (since 2001) and a fellow of the following institutions:College of Medicine (South Africa);Royal College of Surgeons (Edinburgh); Royal College of Ophthalmology (London); a member of the European Society of Cataract and Refractive Surgeons, and of the International Society of Refractive Surgeon; and an international member of the American Academy of Ophthalmologists. He has also held a number of senior posts in South Africa, in both public and private health institutions.

Bythepeople acknowledges the South African Institute of Race Relations, for providing a recording of Dr Letlape’s address given at a briefing in February 2004, on which this article is largely based.