Essential Healthcare Package Proposal

1. Essential Healthcare Package Proposal R Patel, H Wadee & D Pearmain Board of Heathcare Funders of Southern Africa 2006

3. Why Primary Care as Core benefit?

4. Alma Ata (1978) • “Health for All” • PHC

5. WHO • Primary Care … most cost effective… improve health status (Not every primary care service is cost effective)

6. Health Charter in SA • In development • Principles applicable to SADC …Basic Package of health services

7. African Union: Conference of Health Ministers2007 • African Health Strategy: 2007-2015 • 34. This Strategy seeks to advocate and promote a coherent organisational framework that enhances efficiencies and effectiveness through: • “Adopt a primary health care approach” • … • “Determining the package of primary health care that all citizens can access” • …

8. LIMS • No growth in Medical Scheme membership • Large group of low income earners currently using private private sector e.g. GPs and not on Medical aid • Government service for indigent, private sector for those earning • Target is new members • Income below R6500.00 • primary care based, EDL and emergency care. No private sector hospitalisation and Maternity • Funding (R150 per beneficiary per month) • Member • Employer • Tax subsidy (R25 at least- best growth potential) • Provider discounting • Part of existing MS or new New medical Scheme?

9. Limitations of LIMS • Extra chronic benefit • 14 diseases (not equitable)

10. EHP/BBP

11. Guiding principles

12. Benefit Driven Essential Care Primary care focus Individual patient first Insured Benefit Public health first Disease Driven Needs based benefit focus Adapted from Stolk P et al. “Rare essentials”: drugs for rare diseases as essential medicine. WHO Bulletin: Sept 2006, 84 (9)

14. Burden of disease

15. Allocative inefficiency

16. Health Status of SA • Equivalent to developing nation • Essential care required as core • SADC countries • Developing countries

17. Count of deaths by age band

19. Draft primary care benefitsLIMS as core • Consults and • additional consults mild to mod chr.dx. (1GP + another) (ECB) • Full benefit for severe disease (establish objective criteria) • Negative list for ECB • <5year age additional consult benefit • Formulary of GP procedures, side room tests • Hospital level EDL • Formulary of pathology and radiology including additional tests for ECB • Conservative dentistry (2 x 2) • Limited optometry – ISO LESO copper plan • Mental health services (5 treatments) • Emergency transport and care • Maternity care benefits @ primary care fees

20. In hospital benefit • Public sector: appropriate admissions and utilisation • At UPFS Private sector • Maternity and pregnancy states • Sterilisation and TOP • AIDS and related • Trauma • ≤4 years • Notifiable diseases • Rehabilitation services for above where applicable • Cataracts • Other incl. CVD: depends on cost & affordability

21. EHP Suppl 1 Suppl 2 Common Benefit Optional State including Maternity Mandatory Hosp. Public: 100% UPFS Private: Select List Chronic: Hosp EDL & CD benefit LIMS LIMS equav. Maternity Savings Referred care Primary care

22. INPATIENT OUTPATIENT LIMS EHP AdditionalReferred care benefit LIMS Primary care benefit LIMS Primary care benefit REF present view

23. LIMS EHP Other benefit LIMS Primary care LIMS Primary care REF suggestion for EHP

24. Thanks You!