1. Presentation to Global Campaign for Microbicides Consultation: Insurance Funds as options to operationalise access to ART 19 – 20 June 2008 Elaine McKay Head: HIV Strategy

2. 2 Agenda 1. Introducing Medical Schemes and Discovery 2. HIV and AIDS in Discovery Health 3. The HIV Partnership Fund and others

3. 3 What is a “medical scheme” (South Africa) A medical scheme helps you to pay for your healthcare needs, such as nursing, surgery, dental work, medicine and hospital costs. It can be described as “insurance” you are taking out to cover your health costs. You (and in certain cases your employer) pay regular contributions to the scheme. A medical scheme is a non-profit organisation and should be registered at the Registrar of Medical Schemes. A board of trustees who are elected by the schemes’ members manages a medical scheme. They are responsible to manage the scheme to the benefit of its members. The Medical Schemes Act (No 131 of 1998) came into effect on 1 January 2001. Offers a compulsory minimum package of benefits and exclusion of risk rating, and the discrimination on the basis of health, age, race, gender of medical history (important in the context of what would be termed “anti-selection” for trial participants

4. 4 What are the advantages of belonging to a medical scheme You have the security of knowing your medical needs will be looked after A portion of your contribution can be deducted from your taxable income You can budget for your medical expenses You can get the best medical care available in facilities with state of the art equipment and infrastructure You can undergo medical surgery when you need it most and not be put on a waiting list for available doctors to perform the surgery or availability as in the case of state hospitals You will be treated immediately in the case of an emergency without any worries regarding funds available You can benefit on a personal level with different wellness and vitality options available

5. 5 What should a medical scheme pay for? In 2004 the Medical Schemes Act of 131 of 1998 introduced Prescribed Minimum Benefits (PMB). It is a set of defined benefits to ensure that all medical scheme members have access to certain minimum health services, regardless of the benefit option they have selected. The aim is to provide people with continuous care to improve their health and to make healthcare more affordable. PMBs determine that medical schemes have to cover the costs related to the certain diagnosis, treatment and care of medical conditions. Important since HIV and AIDS are covered under PMBs

6. 6 The Discovery Group 2 million lives1.2 million lives 250,000 lives 172,053 policies 59,262 lives89,220 lives Driven by a central mission Statement: To make people healthier and enhance and protect their lives

7. 7 Growth in lives under management 2 million lives 0 500,000 1,000,000 1,500,000 2,000,000 19931994199519961997199819992000200120022003200420052006 Feb 2007 Lives administered Established in 1992 Covering 1 open scheme and 11 Restricted schemes R19 billion in premium income per annum

8. 8 Unique position in market Source: 2006 Global Credit Rating reports and scheme financial results Change in membership ('000) Membership level end 2005 ('000) -40 -20 20 40 60 80 100 200300400500600700800 Oxygen Spectramed FedHealth Medicover Hosmed Resolution BestMe Liberty Munimed ProSano Sizwe Medshield MediHelp Momentum Bonitas Next top 15 open schemes in SA Discovery Discovery is positioned at the centre of the healthcare system

9. 9 Integrated scalable systems provide world class support to Discovery 120,000 claims per day 96% claims within 3 days R 7,000,000 paid per hour 85% paid directly to health professionals Claims 1 patient hospitalised every 56 seconds 35,000 calls answered per day Answer 90% within 20 seconds 92% of calls resolved on first contact R19bn billed annually Service to members Process 1,000 – 1,500 new lives daily 80% processed in less than 2 days New business 14,588 GP consultations paid per day 4,383 Specialist consultations paid every day Interaction with health professionals

10. 10 HIV and AIDS in Discovery Health Medical Scheme Number of members registered on disease management versus estimated prevalence 3,940 6,181 8,937 12,560 0 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000 2004200520062008 (To date) 80,000 Estimated prevalence Members 70% of enrollees require ART at registration

11. 11 Discovery is well positioned to fight HIV Administers over 2 million lives covered by one open scheme and 11 restricted membership schemes Corporate health strategy providing access to wellness days and VCT events Almost 12,000 HIV positive members under management Largest primary care network GP Network with over 3,600 GP’s Provider agreements with over 4,000Specialists

12. 12 HIV Strategy in the Workplace VCT for all Employees HIV (+ve) HIV (-ve) Prevention DHMS or other medical scheme members Uninsured Enroll on HIV disease management programme Identify funding source

13. 13 Funding Options for HIV+ uninsured employees and their family members HIV Insurance Models Direct corporate funding (AngloAmerican, SAB Miller etc) NGO/Bilateral donor funded programmes such as Right to Care, BroadReach Public facilities

14. 14 Insurance for Health Service Delivery in the context of HIV

15. 15 Important issues to consider Reciprocity vs justice Anti-selection (few who seroconvert) vs equity (all participants) ART for few or better health care for all (responsibility to community) Don’t have to do it alone ­Vaccine Initiative ­PharmAccess and Health Insurance Fund ­Civil Society ­donors Opportunity to be innovative and demonstrate impact in a complex trial environment

16. 16 Options for Trial Participants a)Registration of/with a Fund (preferably in country) which: ­are based on risk pooling and thus realise solidarity : offer subsidised contributions from donors ­protect against unexpected financial shocks due to illness ­generate budgets for investments in efficient health care, and ­empower members to insist on high quality health care. ­Funds would cover the costs of case management, of out-of-hospital treatment, including ARV medication (basket of services) where clinically indicated, monitoring tests (CD4/VL) etc. ­Supports the development of better health care facilities where these do not exist (clinic improvement initiatives, better training of doctors and nurses etc.) – leverage current “health systems strengthening agenda ­Could be joint IAVI/IPM Fund with other partners (e.g. donors)

17. 17 Other Options b)Work with an existing medical insurer to design a product for trial participants i.Efficiency and effectiveness would be determined by number of beneficiaries (closed scheme) – issue of who is the employer? ii.Expensive option since risk pool would have to be funded upfront iii.Simpler to manage since administrator would take responsibility for payment of claims etc. (outsource arrangement) c)Purchase disability cover for participants (scope for misuse of funds since money is paid to beneficiary not service provider) Recommendations: Push current boundaries and limitations; explore new and innovative partnerships.