2. Health Systems Republic of South Africa

3. 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.

4. 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

5. 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

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

7. Health Authorities 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

8. 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

9. Process Flow for an insured Individual LOW RISK Health individuals Apathetic & Nostalgic 65% Diseased 20% AVE. WORKFORCE CONTINUUM 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 Time Interfacing 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 Workplace Clinics OCC Health EAP Absenteeism Management Education Executive Health

10. Process flow for an un-insured individual No risk assessment Available Choices of Service 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 Poor Financially Affording Will pay cash for Private Health Care facilities

11. Positives and Negatives of the Public/private debate

12. 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-shifting from employer to employee Provision of low cost healthcare delivery to enable affordable products and access for emerging market 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%

13. 8.5% Health Care Expenditure Expenditure as a percentage of GDP

14. 7 million 37 million Population covered: Private vs. Public Private sector Public sector Health Care Expenditure

15. 7 million 37 million Relative expenditure split Private sector Public sector R 59 billion / 58% R 43 billion / 42% Health Care Expenditure “Chronic inefficiency of distribution”

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

17. 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 RSAUSA 89 9 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 Infectious diseases Tuberculosis HIV and Aids Malaria STD’s Percentage TB cases that are HIV positive 25% Wellness of the nation

19. 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 nation

20. 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

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

22. “…. 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.”