Hospital fees show sick priorities
Poor can't afford state hospitals any longerApril 25, 2005 Edition 1
Solly Benatar
In the past year, fees at state hospitals like Groote Schuur have escalated so much that in some instances it is cheaper for patients to seek the attention of doctors in private practice. But patients who attend Groote Schuur cannot afford private fees.
It is a disgrace that the poor and the needy with chronic diseases, who in previous years could get excellent treatment for an affordable nominal fee, now have the unenviable dilemma of either having to forgo medical care to avoid debt, or live with the shame of receiving escalating monthly bills that they cannot pay.
These fees are not dictated by individual hospitals but are mandated by the national Department of Health.
The present patient clientele at Groote Schuur and similar hospitals includes very few patients who are able to pay for their medical care, as most of our local citizens are poor or just emerging from poverty, earning barely sufficient to take care of their families.
Yet many of these patients are now being charged unreasonable fees.
The only patients who are exempt from charges are those with a social pension from the state, those earning less than R750 a month, disabled persons and those who are formally unemployed.
Major escalation in charges since early 2004, based on national policy, results in charges sometimes exceeding those made in the private sector. For example, a patient earning more than R3 000 a month before tax (or who is a member of a family earning more than R4 166) attending the Groote Schuur respiratory clinic for a follow-up visit, is billed R778 (a R338 consultation fee and R440 for simple lung function tests). This is R391 more than the patient would pay in the private sector.
Patients with chronic diseases that require frequent hospital visits are also seriously compromised. For example, a patient with psoriasis, an uncomfortable and sometimes disfiguring skin disease that can severely impair the quality of life, may require a few minutes of photo-therapy daily at the dermatology clinic.
In late 2002 the monthly bill for such treatment for a patient earning less than R3 000 a month before tax was about R58 - an amount that such patients were willing and able to pay for treatment they appreciated and that made a major difference to their lives. In 2004 the monthly fee for such patients was raised to R700, a 12-fold increase.
Although psoriasis is not a life-threatening disease, it is can be uncomfortable and unpleasant. Patients feel much better when treated, but at current prices many have no option but to forgo treatment so that they can feed their families.
Anyone who earns R3 000 before tax (or who is a member of a family earning up to R4 166) a month and who requires renal dialysis for chronic renal failure - treatment that allows him or her to continue to work and lead a life of reasonably good quality - is charged R910 a month. Anyone who earns between R3 000-R6 000 before tax (or is from a family that earns R4 167 to R8 330 a month) is charged R6 435 a month, which in many cases exceeds the amount earned.
Patients who fall into these categories cannot survive financially under these conditions. But if they do not have dialysis, then they will die within a few weeks.
Admittedly, healthcare costs have escalated but state hospitals have always been run on taxation money. What is going on in the mind of our government when they escalate fees in this way? Only a very small percentage of what it costs to run Groote Schuur services is recovered from fees (less than 5%).
Once the costs of billing and collecting the fees are subtracted, the overall gains are even smaller in relation to total costs. So it seems unlikely that the purpose of patient fees is to generate funds to maintain services.
A more alarming explanation for escalating patient fees is that the state wishes to discourage people from using tertiary public services so that these can be progressively reduced. There is some evidence for this from current trends.
For example, at Groote Schuur the renal dialysis/transplant service has been cut from 156 patients on chronic dialysis and nearly 100 renal transplants done each year in the mid-1990s, to 100 on dialysis and about 75 transplants in 2002 and down to 50 transplants in 2004. There are many other examples of such ongoing cuts to clinical services.
Between 1995 and 2000, the public health sector in the Western Cape was downsized by 3 601 hospital beds (24.4%) and by 9 282 health and support personnel (27.9 %) while the local population increased by 8%.
The number of specialists at Groote Schuur has been reduced from about 200 in 1990 to fewer than 100 in 2003, and the plan is to reduce this further to about 50 by 2010! This will only be possible if services continue to be cut.
The threats to tertiary medical care in the public sector and to medical education by such erosion, as previously described in the Cape Times ("The lost potential of our health system", January 14), are thus accompanied by progressive discouragement of patients from using tertiary services.
It is indeed appropriate in a resource-constrained setting to eliminate use of expensive treatments that result in little if any improvement in the duration and quality of life.
However, it is not appropriate to reduce expectations of access to highly effective treatments that can prolong and improve the quality of life.
These cutbacks and the implementation of escalating fees should be seen in the context of wasteful state expenditure in many areas. For example, consider the amount of taxpayers' money wasted in the public service through maladministration, excessive military expenditure and many extravagant expenditures on public officials.
Consider also the large sums of money lost to the public though travel fraud by well-paid public officials and losses through theft of social welfare grants by corrupt civil servants.
As we witness tertiary care being eroded in the public sector and poor patients being charged exorbitant fees, we need to ask some penetrating questions. Why is it more important to have state-of-the-art military equipment than state-of-the-art medical care in our public services?
Why are hospital fees collected so assiduously while little if any definitive action is taken to recover money fraudulently acquired by paid state employees, and offenders go largely unpunished?
Against this background, the morality of escalating patient fees in state hospitals is open to serious question.
