Why TB and HIV community should care about the private health inquiry

In South Africa, people seek their constitutional right to access to healthcare in the public sector or the private sector, or both. Approximately 19 percent of the population or 8.8 million people use the private health sector, with the remainder relying on the limited resources in the public sector.

The public sector continues to see stockouts of essential medicines, and a shortage of adequate staff, equipment and proper infrastructure. While the private sector is better equipped to deliver healthcare services, those services are out of reach of the majority of people. The inequality in the health system in some ways reflects the inequality in our society.

In January 2014, the Competition Commission launched a far-reaching inquiry into the private health sector to understand the nature of the sector and the way it delivers healthcare services.

Ultimately, the inquiry may deliver recommendations for changes to the system that will go some way to address the inequalities.

SECTION27 has been involved in the inquiry from the very start, emphasising the need for a patient-focused inquiry. The sector is complex, involving hospital groups, manufacturers and distributors of medicines and medical devices, pharmacies, health professionals, medical aid schemes, and, of course, the regulators – the Council for Medical Schemes, Health Professions Council of South Africa and Department of Health – all of which have a public interest mandate to protect members of the public who access the private health system.

In 2011, Andaleeb Rinquest was diagnosed with XDR-TB. Andeleeb spent a lot of money on doctors and tests but could not continue to self-fund her treatment. She sought treatment in the public sector after her health had deteriorated. The treatment was unsuccessful and she was hospitalised again in 2013, in a private hospital. However, Discovery Health, her medical aid scheme, refused to pay for the full treatment of XDR-TB and sent her to the public sector to seek treatment. While treatment for XDR-TB is available in the public sector, it is limited by the high cost of the drugs. SECTION27 lodged a complaint to Discovery, alleging that the refusal to pay for her treatment was a violation of her rights. Discovery eventually paid for her treatment, in the private sector. Andeleeb completed her treatment and is in good health.

Patients living with HIV have also struggled to access treatment in the private sector. ‘ES’, a mother and teacher living with HIV from Pretoria, is a member of Genesis Medical Scheme. Her medical scheme told her to go to the public sector for treatment and to get the clinic to invoice the scheme. However, ES has not disclosed her HIV status and fears being seen collecting treatment at her community clinic. As a teacher, she must be in school early in the morning and stays late, preparing lessons and helping learners in need. She therefore has gone to a private clinic to buy her treatment and funds the entire monthly cost herself as her scheme refused to pay for treatment in the private sector. SECTION27 is also providing legal assistance to ES.

The question, however, still remains: how do the majority of patients navigate this complex system without assistance? The health inquiry is considering these kinds of barriers to access.

All schemes are obliged to pay in full for the diagnosis, treatment and care of HIV/AIDS and TB, regardless of the plan the member and their dependants are on. However, Andaleeb, ES and many others face financial hardship, debt and despair when they try to access their rights to healthcare services through the private sector. The health inquiry is, among other issues, looking at the legal framework and the ability of regulators to meet their mandate to protect all patients. The impact of the failures in the private system on access to health services in the public health system is also an important aspect of the inquiry.

In February 2016, the health inquiry will hold public hearings in which all stakeholders will participate. It is important for patient advocacy groups to participate in this inquiry to ensure that the commission is not only concerned with the complexities of the companies involved in the sector, but that the rights of those who use the system are central to the inquiry.

At the end of 2106, the commission will publish its final report, which may include recommendations for reforms to the sector. SECTION27 believes that any such recommendations must protect the rights of people in the TB and HIV community.