Ethics 2

NO LONGER ACCREDITED. DO NOT COMPLETE FOR CPD PURPOSES

This tutorial is worth 3 CEU’s. This tutorial is worth 3 CEU’s. The 2013 ethics tutorials will cost R200 for 2 tutorials (R400 in total for all 4). Complete the questionnaire at the end of the tutorial and get 70% or more. Once the payment has been received we will email the certificates (see the Get CEU’S page for banking details). Certificates will only be issued on weekdays and may take up to 24 hours

There has been much talk over the last few years about the proposed national health bill particularly amongst health professionals. Despite it being a hot topic, little is known regarding the bill and its implementation. The following article, including a publication by Consultancy Africa Intelligence examines the pros and cons of proposed bill.

National Health Bill

To provide a framework for a structured uniform health system within the Republic, taking into account the obligations imposed by the Constitution and other laws on the national, provincial and local governments with regard to health services; and to provide for matters connected therewith.

Preamble

Recognising:
* the socio-economic injustices, imbalances and inequities of health services of the past;
* the need to heal the divisions of the past and to establish a society based on democratic values, social justice and fundamental human rights;
* the need to improve the quality of life of all citizens and to free the potential of each person;
Bearing in mind that:
* the State must, in compliance with section 7(2) of the Constitution, respect, protect, promote and fulfil the rights enshrined in the Bill of Rights, which is a cornerstone of democracy in South Africa;
* in terms of section 27(2) of the Constitution the State must take reasonable legislative and other measures within its available resources to achieve the progressive realisation of the right of the people of South Africa to have access to health care services, including reproductive health care;
* section 27(3) of the Constitution provides that no one may be refused emergency medical treatment;
* in terms of section 28(1)(c) of the Constitution every child has the right to basic health care services;
* in terms of section 24(a) of the Constitution everyone has the right to an environment that is not harmful to their health or well-being;
and in order to—
* unite the various elements of the national health system in a common goal to actively promote and improve the national health system in South Africa;
* provide for a system of co-operative governance and management of health
services, within national guidelines, norms and standards, in which each province, municipality and health district must address questions of health policy and delivery of quality, health care services;
* establish a health system based on decentralised management, principles of equity, efficiency, sound governance, internationally recognised standards of research and a spirit of enquiry and advocacy which encourages participation;
* promote a spirit of co-operation and shared responsibility among public and private health professionals and providers and other relevant sectors within the context of national, provincial and district health plans,

Health financing and the National Health Insurance in South Africa: An overview
Article by: Consultancy Africa Intelligence CAI 1

Written by Deanne Goldberg

(1) http://www.polity.org.za/article/an-overview-of-health-financing-and-the-national-health-
insurance-in-sa-2012-04-17

No matter their level of income, all people desire protection from the personal and financial risks associated with ill health.(2) Nevertheless, each year millions of Africans face financial crisis as a result of insufficient means to access adequate health services.(3) As a result of the rising numbers of people with little or no access to basic health services, countries across Africa have recently placed healthcare high on their development agendas. In South Africa, this critical human right to health and protection from risks are enshrined in the Constitution.(4) In order to combat socio-economic discrepancies and inequalities in access to health services, the South African Department of Health has proposed the National Health Insurance (NHI) as a “financing system that will make sure that all citizens of South Africa (and legal long-term residents) are provided with essential healthcare, regardless of their employment status and ability to make a direct monetary contribution to the NHI Fund.”(5)
This discussion paper presents a brief introduction to the principles of universal coverage and the nature and content of the proposed NHI plan. It will then move on to discuss the potential benefits and challenges of the NHI based on differing opinions held by major stakeholders.

Health financing and universal coverage in an African context
With high levels of burden of disease (BOD) globally and on the African continent particularly, health financing has become an increasingly important area of concern for policy makers and healthcare providers. While Africa is home to only 12% of the world’s population, its disease burden is vastly disproportionate,(6) with Sub-Saharan Africa alone accounting for 22% of the global BOD.(7) This region also accounts for only 1% of the world’s health expenditure and 2% of the global health workforce, making it concurrently one of the worst-affected and most ill-equipped to combat its poor health status.(8) For example, 2005 estimates suggest that in Kenya and Senegal over 100,000 households, and in South Africa over 290 000 households, were forced below the poverty line due to their healthcare expenditure.(9)

The low levels of domestic investment in healthcare in some African countries have significantly impeded their progress towards the Millennium Development Goals compared to their global counterparts.(10) Large gaps exist between the resources needed and those available to respond to the health challenges. Health system bottlenecks, coupled with poor resource mobilisation, mean that governments’ capacity to respond to health crises becomes increasingly complicated.(11)

The South African government, among others, has therefore called for a move to a national health insurance policy. This type of system is premised on the idea of universal coverage promoted by the World Health Organisation (WHO). This approach proposes a healthcare delivery system whereby financial expenditure is managed so as to share risk amongst all individuals in a population and prevent impoverishment as a result of seeking care. Under a system of universal coverage, infrastructure and human resources for healthcare should be sufficient to support the provision of equitable, quality health services. Three major health-financing functions are regarded as central to achieving universal coverage: revenue collection, pooling of resources and purchasing and provision of services.(12) Countries developing such plans must consider the unique macroeconomic, political and socio-cultural profile of the nation and should, where possible, capitalise on pre-existing relationships. Collaboration between private and public service providers, guided by strong government stewardship, is essential. Sharing of successful development experiences across the healthcare spectrum in order to enhance service delivery across the board is encouraged.(13)
Healthcare in South Africa: Introducing a National Health Insurance(14)

The South African healthcare system includes private and public service providers.(15) The public healthcare system is funded primarily by the fiscus and, as far as possible, provides free care at the point of service to the majority of South Africans. Due to high patient volumes and poor funding, the public healthcare system is often associated with being poor on safety, patient management, stock availability and infection control. This has resulted in poor staff morale, under-maintained facilities and an overall compromised quality of service provision in public health facilities.(16) The private sector services a smaller portion of the population who, by virtue of their employment status, elect to purchase benefit options through a medical scheme or pay out-of-pocket.

An estimated 8.3% of South Africa’s gross domestic product (GDP) is spent on healthcare. Of this, 4.1% is spent on the 16.2% of the population using private sector healthcare services. The remaining 4.2% serves the 83.8% of the population using public healthcare services. This discrepancy in the distribution of funding has created a tiered and polarised healthcare system. Historically inequitable service provision among population groups, declining infrastructure and the increasing cost of health have meant that the gap between the private and public health sectors has grown increasingly wide. It is now imperative that the problems facing many South Africans as a result of poor and biased health financing be addressed.
The development of a national health system has been a focal point of discussions and proposals surrounding health sector reform, and is guided by the tenets of the African National Congress’s (ANC) 1994 National Health Plan.(17) Following consultation with the Ministry of Health’s National Health Insurance Advisory Committee, the NHI Green Paper was released in August 2011 for public comment.(18) The introduction of the NHI endeavours to eliminate the flaws of the current system by improving access and ensuring financial risk protection against the high expenditure associated with healthcare. Implementation would ensure all South Africans equitable and sustainable access to quality healthcare based on the severity of illness rather than financial capacity.

The fundamental offering of the proposed NHI is that all South Africans, irrespective of employment status, will have access to a pre-defined comprehensive health service package. This package will make care available at all levels with guaranteed continuity of benefits. Services provided will be within the bounds of that considered achievable for implementation, commensurate with national resources. Co-payments at the point of service may only be necessary when services are beyond those defined under the benefits package. Ultimately, the NHI seeks to create fairness in the sharing of healthcare finance and other resources, including the distribution of skilled health professionals. By pooling funds and risks between the rich and poor, healthy and unhealthy, young and old, the NHI may achieve equity and social solidarity.

International evidence suggests that benefit packages should be determined by an assessment of the most pressing needs of the particular recipient group and prioritise enhanced accessibility of healthcare services. The package norms to be provided in geographic districts will assist in determining appropriate and measurable targets. These will be implemented according to certified service provision standards. Such norms will enable managers at all action levels to compare and contrast performance and challenges between individual and groups of similar facilities.

The Green Paper proposes seven guiding principles for the development, implementation and sustainability of a national health insurance policy, which aim to consolidate and coordinate the value and effectiveness of implementation. These are: right to access, social solidarity, effectiveness, appropriateness, equity, affordability and efficiency.
The NHI aims to reduce direct costs for healthcare felt by families and households, and thereby prevent cases in which households are forced to face impoverishing and potentially catastrophic consequences as a result of healthcare costs. The NHI is configured so that those individuals earning above a specified income level will be required by law to make a monthly NHI payment,(19) while those with incomes below this threshold will not be required make any direct payments to the fund. Further, employers would have a role to play in coordinating and supporting their employees’ contributions. Payment would be aligned with an individual’s ability to pay, and benefits aligned with the individual’s need for care. However, the precise parameters and conditions for payment are not specified in the Green Paper as it stands.

The Green Paper contends that to create the systems necessary to support the NHI successfully, an improvement in healthcare quality and pricing regulation, as well as the rigour of planning, service provision, information management and administrative systems is paramount. In order to coordinate national healthcare access information, two important mechanisms to support implementation have been identified. For a citizen to receive treatment under the NHI, they will need to be registered with the Department of Home Affairs. The creation of a coordinated and integrated health information system will support enhanced efficacy, confidentiality, portability of information, decision making and systems planning. This will enable improved availability of information for healthcare providers regarding services dispensed across the population, no matter the site or provider. Information gathered in this way will provide useful and representative indicators for tracking the dispensation of the health funds and monitoring BOD at national, provincial and district levels.

In order to implement the NHI’s financing mechanism in a manner that will benefit the entire population certain key activities need to occur simultaneously. These include the complete and total overhaul of the healthcare system, as well as service provision and delivery. Administration and management need to be radically altered. In particular, the primary health care system needs to be re-engineered to underpin the provision of a functional and comprehensive care package.(20) Work is already underway in the National and Provincial Departments of Health to support the delivery of primary health care services. Importantly, service delivery will be population-oriented and draw on community capacity and infrastructure, including local health workers and home-based healthcare. This reinforces the move away from hospi-centric model of care that has dominated until recently and will also assist the under-performing institutions in the public sector which have suffered a decline in service quality and capacity due to inadequate funding, poor management and decaying infrastructure. The improvement in resourcing will be a primary focus during the first seven years of implementation, as the re-engineering of the primary health care system is regarded as an urgent intervention.

The district health system (DHS), supported by district clinical specialist and support teams will be the vehicle by which all primary health care is delivered. The district team will aim to integrate the activities of general practitioners and hospital-based specialists and to provide support to those working in primary care. The implementation of stringent treatment guidelines and protocols, coupled with enhanced human resources will serve to enhance the quality of service provision.

The Ministry of Health has begun to take action to facilitate the implementation of the NHI and revitalise the system’s capacity for quality healthcare service provision. Included in these efforts are the improvements of the facilities of six major public hospitals supported by private companies, and the drafting of legislation to ensure that all those in supervisory or management roles are appropriately qualified and experienced. A regulative body called the Office of Health Standards Compliance (OHSC) will be responsible for the inspection and accreditation of hospitals, facilities and practitioners to ensure that they are in compliance with the required standards. This regulatory body will be legislated through three main divisions: inspection, norms and standards, and the office of the ombudsperson. All healthcare providers that wish to be considered for rendering health services will have to meet set standards of quality to be accredited by the OHSC. Regular assessments will be conducted to ensure that set standards are maintained. The results will be used to guide recommendations for quality improvement in public healthcare facilities with associated training.

The Green Paper lays out a timeline in three phases over a projected 14 years, beginning in 2011 with the publication of the White Paper and reaching full implementation in 2025. This is based on estimates from implementation processes from other countries, which have suggested that capacitation of facilities and healthcare providers to accommodate the utilisation increases associated with the NHI will take time.

Beginning April 2012, the NHI will be piloted in 10 priority districts, selected on the basis of an audit conducted by the National Department of Health. The audit will take into account the state of healthcare facilities, as well as a number of key indicators. Selection will be informed by district demographic and health profiles, service delivery and performance, income levels, quality standards compliance and socio-cultural profiles. This pilot will inform the structure of governance and district management systems, as well as serve as a mechanism for testing the rollout of the proposed NHI service package. The pilot will be extended at a later point to 20 districts. Ultimately this capacitation process will serve to strengthen the proposed District Health Authority – a contracting unit charged with managing contracts through the relevant accredited provider.

Is it affordable?
The current fragmented healthcare system, characterised by its high-cost, hospi-centric and curative approach, is regarded as unsustainable. In contrast, preliminary costing estimates suggest that the NHI is affordable and sustainable. The funds will be drawn from a combination of sources (e.g. individuals, employers and the fiscus). To implement this will require that payments for healthcare are made in advance of an illness, and that these are pooled and used to fund health services for the population. The precise combination of sources is the subject of continuing technical work and will be clarified in parallel with public consultation. The NHI Fund will be established as a government- owned entity that is publicly administered with the South African Revenue Service being responsible for revenue collection.

To implement the NHI, an increase in health expenditure – through tax revenue and the mandatory contribution – that exceeds projected GDP increases is required. However, the level of spending necessary to achieve universal coverage in this way is less than that being spent currently by government and through medical schemes – an estimated R227- billion is currently being spent on healthcare services in South Africa (inclusive of private and public health-spend).
Finance Minister Pravin Gordhan, addressing the issue of the feasible introduction of the NHI, has stated that he sees “no immediate risk of a fiscally unsustainable process emerging.”(21) He stressed that the envisioned long-term implementation program would focus on enhancing the public health sector’s capacity to provide quality health care. He further emphasised the government’s commitment to ensure sustainability throughout this process and to ensure the proper management of inter-generational debt.(22)
Professor Di McIntyre has supported this and suggested that the required spend to implement the NHI would approximately match the amount currently spent by government on healthcare.(23) An investigation by KPMG auditors on whether the cost- benefit of the investment in healthcare proposed in the NHI outweighs the tax payments needed to fund it over the proposed 14 year implementation period, notes that there remains potential for the NHI to improve the health of the population and in turn increase the GDP of the country as a whole.(24) However, opposing these views, director of Econex, Nicola Theron, has stated that at an estimated minimum cost of R196 million the implementation of the NHI may well be unaffordable.(25)

Opportunities and potential benefits of NHI
Considering debates regarding the affordability of implementation, KPMG Head of Health for Africa and South Africa, Sven Byl, reminds that, “When analysing the potential cost of NHI, one can fall into the trap of considering healthcare expenditure only as a cost to the economy. Spending on healthcare is a long-term investment in the human capital of South Africa.”(26) This highlights the potential impact of sustainable and equitable access to healthcare on the productivity of the nation.
The benefits package available to all citizens under the NHI will contain health promotion, disease prevention, curative and rehabilitative components.(27) This represents an enhancement of a previous model primarily focused on curative interventions rather than holistic healthcare.

Dr.Motsoaledi reminds that although the private sector and medical schemes are also affected by the introduction of the NHI, the NHI should not be conceptualised as a war between private and public sector health coverage.(28) Private hospital and specialist costs have increased by approximately 120% each over the past decade, which has created a situation whereby service access is insufficient as a result of schemes’ and benefit packages’ designs.(29) Costs of private health care are escalating faster than the costs of living, and the NHI aims to repair this gap in access by providing equitable access to necessary services and thereby reduce reliance on private healthcare funding.

In his recent state of the nation address, President Zuma noted that the government has prioritised NHI implementation through “critical social infrastructure projects.”(30) These include dedicating national efforts to the refurbishment of healthcare facilities. Re- engineering of the primary healthcare system will place considerable focus on health promotion and preventative care aspects. This re-orientation of the healthcare system has the potential to significantly improve South Africa’s national health status.

“Strong on the what, but less so on the how”: Critiques and potential challenges
KPMG’s Director of Global Health, Dr. Mark Britnell, has described the Green Paper as: “strong on the what, but less so on the how.”(31) Two of the major critiques of the Green Paper noted by commenting parties, political and academic, are that the concept of the basic “benefits package” is not expanded on to explain what benefits this would include. It is further contended that funding requirement estimates are inadequately explained and do not accommodate for price inflation.
The Congress of South African Trade Unions (COSATU) has welcomed the NHI but also openly expresses its concern regarding the inclusion of medical schemes in a “multi- payer” system, suggesting that this will sustain inequitable service delivery and “undermine” the implementation of the NHI.(32)

The Democratic Alliance (DA), the ANC’s primary opposition, has released a position paper which suggests that the Green Paper is founded on the faulty notion that the government’s failures in health service delivery are as a result of private sector success.(33) It further contends that, “the promotion of such an argument suggests that the Health Ministry not only misunderstands what is wrong with healthcare, but remains blind to its own responsibility in creating the problems the health system now faces.”(34) The Helen Suzman Foundation (HSF) has echoed this sentiment in their position paper, highlighting a lack of evidence-based support for claims that private and public sector inequalities are the primary cause for poor health outcomes and the state of South African healthcare.(35) The DA also notes an approximately 30% difference in levels of patient satisfaction between public and private health consumers, with the latter experiencing considerably higher levels of satisfaction. They also recommend that by incentivising healthcare practitioners to enhance performance, levels of patient satisfaction in the public sector may increase.(36) The DA offers ten reasons why the NHI is not the solution to the nation’s current health crisis, including statements such as “We lack the human resources to implement NHI,” “NHI does not adequately attend to accountability and management structures” and “NHI eradicates freedom of choice for healthcare consumers.”

Professor Alex van den Heever has suggested that the establishment of a centralised fund may carry considerable risk and destabilise an already unsteady, under-performing public health sector. He suggests that decentralisation of funding is critical to efficient functioning at a provincial level, and that political governance models may be insufficient to accommodate the administrative and procurement responsibilities central to an effectively implemented NHI.(37)
Professor Heather McLeod has called attention to an interesting clarification that must be made between universal coverage for healthcare, and universal coverage for health insurance. She points out that while less than one in five South Africans have insurance coverage, all have access to healthcare through various channels of service delivery.(38)

Way forward
Given the current multiplicity of opinions regarding the validity of the proposed NHI implementation plan, it is certainly valuable to consider the state of commentary and opinion. The HSF position paper notes that public consultation, key stakeholder engagements and dialogue with civil society are imperative to providing clear stewardship and preventing the spread of misinformation.(39) This consultation process will guide the development of a consolidated White Paper, which will be implemented in legislation after approval by Parliament, and ultimately approved as a Bill by the President of the Republic.(40) The timeline laid out in the Green Paper recommended that this process be complete at the close of 2011, however, to date a White Paper has not been released.(41) Acknowledging this however, to create a national insurance plan that is the cumulative result of the consultation recommended here may require a longer period for consolidation.

Conclusion
This paper presents a brief overview of the proposed introduction of a National Health Insurance in the context of South Africa’s current health profile. The NHI aims to provide equitable, quality healthcare to all South Africans, regardless of employment or socio- economic status. By improving the quality of healthcare and ease of access, the health of the nation will be improved and BOD reduced. The voices of proponents and opponents have resonated across sectors, and consolidation of the results of these stakeholder consultations will inform the ultimate form of the National Health Insurance Plan. All agree,however ,that equal access to health services for all South African is and must remain the primary goal.

NOTES:
(2) Carrin, G., et al., ‘Universal coverage of health services: Tailoring its implementation’, Bulletin of the World Health Organisation No. 86, 2008, http://www.who.int.
(3) ‘Social Health Protection: An ILO strategy towards universal access to health care’, International Labour Organization, 2008, http://www.ilo.org.
(4) ‘Constitution of the Republic of South Africa Act’, South Africa Government Online, 1996, http://www.info.gov.za.
(5) ‘National Health Insurance’, Department of Health of the Republic of South Africa website, 2011, http://www.doh.gov.za.
(6) Kaberuka, D., 2011. Africa’s health and the Commission on Macroeconomics and Health. The Lancet, 378, pp. 1904-1905.
(7) Atim, C., ‘Health financing in Africa: Challenges and opportunities for expanding access to quality health care’, 4-8 May 2009, http://www.africa-union.org.
(8) Ibid.
(9) ‘Social Health Protection: An ILO strategy towards universal access to health care’, International Labour Organization, 2008, http://www.ilo.org.
(10) Evans, D.B., Elovainio, R. and Humphreys, G., ‘The World Health Report: Health systems financing: The path to universal coverage’, World Health Organisation website, 2010, http://www.who.int.
(11) Atim, C., ‘Health financing in Africa: Challenges and opportunities for expanding access to quality health care’, 4-8 May 2009, http://www.africa-union.org.
(12) Carrin, G., et al., ‘Universal coverage of health services: tailoring its implementation’, Bulletin of the World Health Organisation No. 86, 2008, http://www.who.int.
(13) ‘Sustainable health financing, universal coverage and social health insurance’, World Health Organisation, 25 May 2005, http://www.who.int.
(14) This section is based primarily on the NHI Green Paper. Unless otherwise stated, references are assumed to be from: ‘National Health Insurance in South Africa: Policy Paper’, Department of Health of the Republic of South Africa Government Gazette No. 34523, 12 August 2011, http://www.samedical.org.
(15) ‘Republic of South Africa: National Health Bill’, Department of Health of the Republic of
South Africa website, 2003, http://www.doh.gov.za.
(16) McIntyre, D., ‘Why we need NHI now’, Health-e News Services, 17 June 2009, http://www.health-e.org.za.
(17) ‘A National Health Plan for South Africa’, ANC, 30 May 1994, http://www.anc.org.za.
(18) Motsoaledi, A., ‘Media statement – release of Green Paper on National Health Insurance’, Department of Health of the Republic of South Africa website, 11 August 2011, http://www.doh.gov.za.
(19) ‘National Health Insurance: Healthcare for all South Africans’, Department of Health of the Republic of South Africa website, 2011, http://www.doh.gov.za.
(20) Shishana, O., ‘National Health Insurance: Green Paper’, Province of KwaZulu-Natal Department of Health website, 12 August 2011, http://www.kznhealth.gov.za.
(21) ‘Gordhan calms fears on NHI’, Independent Online: Business Report, 27 October 2011, http://www.iol.co.za.
(22) Ibid.
(23) Parker, F., ‘NHI will cost same as current healthcare’, Mail & Guardian, 10 September 2010, http://uct-heu.s3.amazonaws.com.
(24) ‘Funding NHI: A spoonful of sugar?’, KPMG, 2011, http://www.kpmg.com/ZA.
(25) Parker, F., ‘NHI will cost same as current healthcare’, Mail & Guardian, 10 September 2010, http://uct-heu.s3.amazonaws.com.
(26) ‘Funding NHI: A spoonful of sugar?’, KPMG, 2011, http://www.kpmg.com/ZA.
(27) Ibid.
(28) Motsoaledi, A., ‘Media statement – release of Green Paper on National Health Insurance’, Department of Health of the Republic of South Africa website, 11 August 2011, http://www.doh.gov.za.
(29) ‘National Health Insurance in South Africa: Policy Paper’, Department of Health of the Republic of South Africa Government Gazette No. 34523, 12 August 2011, http://www.samedical.org.
(30) Zuma, J., ‘State of the Nation address by His Excellency Jacob G Zuma, President of the Republic of South’, 9 February 2012, South Africa Government Online, http://www.info.gov.za.
(31) Thom, A., ‘NHI plan needs clarity on the “how”’, Health-e News Services, 22 September 2011, http://www.health-e.org.za.
(32) Craven, P., ‘NHI Green Paper welcomed’, COSATU, 11 August 2011, http://www.cosatu.org.za.
(33) ‘The DA’s alternative to the NHI’, Health-e News Services, 2011, http://www.health- e.org.za.
(34) Ibid.
(35) ‘Submission to National Department of Health: National Health Insurance Green Paper’, Helen Suzman Foundation, December 2011, http://www.hsf.org.za.
(36) ‘The DA’s alternative to the NHI’, Health-e News Services, 2011, http://www.health- e.org.za.
(37) Van den Heever, A., ‘Evaluation of the Green Paper on National Health Insurance’, 20 December 2011, http://www.hsf.org.za.
(38) Thom, A., ‘NHI plan needs clarity on the “how”’, Health-e News Services, 22 September 2011, http://www.health-e.org.za.
(39) ‘Submission to National Department of Health: National Health Insurance Green Paper’, Helen Suzman Foundation, December 2011, http://www.hsf.org.za.
(40) ‘National Health Insurance’, Department of Health of the Republic of South Africa website, 2011, http://www.doh.gov.za.
(41) ‘National Health Insurance in South Africa: Policy Paper’, Department of Health of the Republic of South Africa Government Gazette No. 34523, 12 August 2011, http://www.samedical.org.
Edited by: Consultancy Africa Intelligence CAI

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Ethics 3

NO LONGER ACCREDITED. DO NOT COMPLETE FOR CPD PURPOSES

This tutorial is worth 3 CEU’s. This tutorial is worth 3 CEU’s. The 2013 ethics tutorials will cost R200 for 2 tutorials (R400 in total for all 4). Complete the questionnaire at the end of the tutorial and get 70% or more. Once the payment has been received we will issue the certificates (see the Get CEU’S page for banking details). Certificates will only be issued on weekdays.

Professionalism

Medicine, encompassing the allied health occupations may be considered a profession. By its very definition the term ‘profession’ sets a high standard. The words ‘profession’ and ‘professional’ are derived from the Latin word professio, meaning ‘a public declaration with the force of a promise’.

The marks of a profession are:

1) Competence in a specialized body of knowledge and skill
2) An acknowledgment of specific duties and responsibilities toward the individuals it serves and toward society
3) The right to train, admit, discipline and dismiss its members for failure to sustain competence or responsibilities.

Professionals thus have the responsibility to act or behave in certain manner and have the knowledge that failure to do so may result in disciplinary action from fellow members or society in general. All professions have a code of ethics stating the standards by which its members must behave. Other professions include law, education and the clergy.

In South Africa’s large scale private health care industry, the line between a business and a profession is often blurred as it is a multi-billion rand industry. However, one crucial difference distinguishes professionalism from business: professionals have a duty toward those they serve. This means that professionals must ensure that their decisions and actions serve the welfare of their patients or clients, before their personal gain. Professions have codes of ethics which specify the obligations arising from this duty and ethical issues often occur when this boundary is crossed

The following principles define the basis of health professionalism:

Altruism: an obligation to attend to the best interest of patients, rather than self-interest.
Accountability: to patients, to society and to the profession.
Excellence: commitment to life-long learning and continuing professional development
Honor and integrity: a commitment to being fair and truthful in interactions with patients and the profession.
Respect: for patients and their families and other health professionals

The Health practitioner- patient relationship.

Fiduciary derives from the Latin word for “confidence” or “trust”. This trust between the patient and the health professional is vital to the diagnostic and therapeutic process and indeed forms the basis of the relationship. In most cases accurate diagnoses and management require unimpeded communication regarding illness or injury.

This relationship has dramatically evolved over the years. Previous, the health practitioner-patient relationship involved patient dependence on the physician’s professional authority. Beliefs that the patient would benefit from the professionals actions and superior knowledge meant that their preferences were usually not taken into account.

Over the last few decades, this relationship has moved towards a partnership of shared decision making. This newer model respects the patient as an autonomous entity with a right to hold views and to make informed choices and decisions based on personal knowledge and beliefs. Patients have been increasingly able to consider the benefits and risks of alternative treatments, or of no treatment, whatsoever. They have been shown to respond well to a clinician who adds a personal touch to the encounter as this likely humanizes them and makes it easier to connect. It is however, essential to maintain professional integrity and make sure that the patient and their concerns, are the focus of every visit.

This ‘softening’ of the boundaries of the patient clinician relationship has created new difficulties. One of the toughest tests of this already tenuous relationship is when a health professional faces requests for services, which may raise a personal or religious conflict for the physician. Abortion is one that comes immediately to mind. Clinicians have the right to not provide medical services in opposition to their personal beliefs but professionalism dictates that while they may decline to personally provide the requested service, the patient’s decision must respected. Alternatives may be discussed in a thoroughly non-judgmental or self-serving manner, but should the patient so desire, and if legal, they should be provided with resources about how to obtain the desired service.

‘There are patients, and there are patients. The difficult ones can be “demanding,” “noncompliant,” “whiny,” “entitled,” or “manipulative.” They can be too different from or too similar to the clinician, too seductive, too unclean, too smart, too fat, too thin, or too anxiety-provoking …’ Roberts and dyer 2003

Negative or overly positive reactions evoked by the patient provide a serious ethical pitfall. Difficult patients are at risk of receiving care that deviates from usual ethics standards. Clinical neglect of patients is more likely when they are unlikable, frustrating, noncompliant, extraordinarily tragic, or otherwise atypical. On the opposite end of the spectrum, when patients closely resemble their caregivers in terms of having similar backgrounds, professions, or interests, professional boundaries may also be crossed. The clinician and patient may begin relating to one another in a manner more congruent with a friendship than a professional relationship.

Barriers to effective clinician-patient communication are very common from a patient’s perspective. They may feel that they are wasting the clinician’s time; omit details of their history which they deem unimportant or embarrassing and not elaborate as they believe the medical professional is disinterested.

Generally maintaining a professional facade and paying attention to personal feelings helps to avoid a number of these issues. The following list provides some guidelines in this regard. Think closely if these steps apply to your personal interactions.

Sit down
Make sure the patient is comfortable
Establish eye contact
Listen without interrupting
Show attention with nonverbal cues, such as nodding
Allow silences while patients search for words
Be positive during examinations
Explain thoroughly using props (books, models etc.)

In essence the patient / clinician relationship is the basis of medicine and supersedes diagnostics and intervention. It thus makes little sense that it is often neglected. Like becoming a skilled diagnostician or practitioner it requires much practice and attention to detail.

Informed consent

As mentioned above, there has been a marked shift in the health practitioner patient relationship. Informed consent has had a significant role to play in this change. It is in essence the process by which a fully informed patient can participate in choices about his or her health care. It originates from the legal right the patient has to decide what happens to their body and from the ethical duty of the clinician to fully involve the patient in their health care.

Mainly due to increasing medico-legal pressure, most invasive procedures requiring some form of anesthetic in South Africa, require signed informed consent. As mentioned above the patient has a full ethical and legal right to the information that will provide them an adequate understanding of the procedure and the risks and benefits thereof. Good explanation will, also likely improve communication and compliance. Lack of knowledge is thus disadvantageous on all fronts.

With Full informed consent it is necessary to consider and fully explain following elements:

1) The process and nature of the proposed intervention and risk and benefits thereof
2) Potential alternatives and associated pros and cons
3) Analysis of patients understanding of the procedure
4) Voluntary and competent acceptance of the intervention by the patient

Basic consent for less rigorous procedures (i.e. tetanus injection) entails informing the patient what you would like to do and them verbalizing consent.

Contrary to what many clinicians have thought in the past, a number of studies have shown that patients want to be told the truth about diagnosis and prognosis. In a recent study 90% of patients surveyed said they would want to be told of a diagnosis of cancer or Alzheimer’s disease. This change in thought process follows through to health practitioners. For example, whereas in 1961 only 10% of physicians surveyed believed it was correct to tell a patient of a fatal cancer diagnosis, this had by 1979 increased to 97%.

In emergency incidences when a person is unconscious or incapacitated, informed consent may be presumed and the clinician is expected to select the best course of action available to assist the patient. Other cases may not be as cut and dry. In cases where the patient displays obvious decision making difficulty or inconsistency that is deemed to be disadvantageous to health outcomes, a family member may be consulted to help with the informed consent process. This is obvious a legally and ethically difficult situation and clinicians must proceed with due caution.

Confidentiality

Confidentiality is one of the ethical cornerstones of modern medical practice. Despite this, it is a daily challenge.

The nature of health professions dictates that patients share extremely personal information with clinicians. It is the moral, ethical and professional duty of the health professional to respect the patient’s trust and keep this information confidential. Failure to do so may open a medico legal ‘hornets’ nest’ and if discovered will at the very least destroy the professional relationship.

The conflict lies in the fact that often, it is critical to patient care to discuss their case with other professional. This is obviously an integral part of the learning experience in a teaching hospital. Precautions must however be taken. Discussions must occur in a professional setting and must be limited only to those integral to the discussion. Where possible exclude the patients name from the discussion and care must be taken, to limit the ability of others to hear or see confidential information.

In certain settings, such as trauma, flippantly discussing cases in the cafeteria or the lift, almost seems to be a means of coming to terms with a highly stressful environment. This does not however make it ethically correct!

There are cases when confidentiality may be legally breached. In such cases it makes legal sense to discuss the case with a superior. In essence one needs to clinically reason if maintaining confidentiality will bring about greater harm than disclosing confidential information. Two instances when this might occur are:

1) Individuals or groups are placed in danger by a patient (homicidal tendencies)
2) Concern for public welfare due to infectious disease

While often the health professional feels compelled or justified to share confidential information regarding the patient with family members, without explicit permission from the patient, it is generally not ethically justifiable to do so. This is once again at the discretion of clinician and notable exceptions would include severe trauma cases

Medical mistakes


All health professionals will, at some stage, make mistakes. The majority of mistakes will not be considered negligence. Numerous factors may force mistakes and in the medical setting, lack of sleep and patient numbers often play a significant role

As discussed in detail above, medical professionals have an ethical and legal responsibility to be truthful with their patients. This includes situations in which a patient suffers consequences, serious or otherwise, because of an error. Medical professionals should not take decisions to withhold information lightly and before making these decisions should at the very least discuss them with another professional. The clinician must be prepared and able to publicly defend a decision to withhold information about a mistake from the patient.

In South Africa, litigation has not yet reached the levels it has in the USA and the UK, but public awareness surrounding legal rights and the ability to sue is definitely on the increase. In the USA where litigation is a common occurrence, it has been shown that patients are less likely to consider litigation when a physician has been honest with them about mistakes. Lawsuits are often initiated because a patient feel the truth has been withheld. Furthermore, clinicians who have been dishonest are not likely to do well in the legal situation.

One of the main reasons for withholding information regarding mistakes is the fear of looking foolish in front of the patient and perceived loss of trust in the medical professional by the patient. This is a well-founded fear. Hhowever, Loss of trust and legal consequences will be more serious if a patient discovers that errors have been hidden from them.

One of the most difficult situations occurs when a health professional bears witness to a mistake by a colleague, as this places the professional in an awkward and difficult position. Professionals often feel the necessity to protect their own and to maintain their social position within the professional setting. Nevertheless, it is the ethical, legal and moral obligation of the health professional to tell the truth regarding the error. This is obviously an extremely delicate situation and before taking it forward, the clinician must be absolutely certain an error was made. Generally the best course of action is to initially discuss the situation and encourage the professional to disclose their mistake to the patient. Should they refuse; the professional will need to decide whether the error was of enough consequence to justify taking the case to a supervisor. At this stage it is probably a good idea to inform the offending party of your decision to do so. Directly informing the patient is unlikely to be a good path to follow as it carries a sense of ‘telling on’ the offending clinician and will not appear professional to the patient.

Accreditation: Accreditation: PPB004-MD271-0023-2-2013

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Ethics 4

NO LONGER ACCREDITED. DO NOT COMPLETE FOR CPD PURPOSES

This tutorial is worth 3 CEU’s. This tutorial is worth 3 CEU’s. The 2013 ethics tutorials will cost R200 for 2 tutorials (R400 in total for all 4). Complete the questionnaire at the end of the tutorial and get 70% or more. Once the payment has been received we will issue the certificates (see the Get CEU’S page for banking details). Certificates will only be issued on weekdays.

Law and Medical Ethics


Law is the established social rules for conduct; a violation of law may create criminal or civil liability.

Medical ethics<; is a discipline / methodology for considering the implications of medical technology / treatment and what ought to be.

There is significant overlap between law and medical ethics and good ethics has been described as beginning where the law ends. Law and medical ethics thus share the goal of creating and maintaining order in a medical setting. Often when legal issues arise in a health care scenario so too do ethical issues. Conversely, what is originally identified as an ethical problem may raise legal concerns. Although South Africa has yet to reach the stage where litigation against health professionals, for negligence, perceived or real, is a daily occurrence, there has been a steady increase in medical malpractice litigation. This is likely due to patients increasingly become aware of their rights as well as a chronically overburdened health system and limited resources. Legitimate claims obviously need to be compensated but increased litigation has other consequences, including: decreased finances for state sponsored health due to large payouts and a continuing increase in malpractice premiums in the private sector. In certain countries, the USA being the most notable, litigation is part and parcel of their practice. Hospitals have dedicated legal teams and professional insurance for health practitioners is extremely expensive. A healthy tension between the medical and legal professions should lead to an overall improvement in quality of health care, but the risk of constant litigation can lead to further pressure on scarce resources. Practitioners in the USA often perform seemingly unnecessary investigations to avoid ‘missing’ something. Adequate state funding will naturally reduce the risk of claims that result from inadequate human and other resources. The recent implementation of the Consumer Protection Act will place additional and direct responsibility on health professionals for claims made by patients for which they may be directly or indirectly held responsible

Despite the overlap, there are significant distinctions between law and medical ethics in terms of philosophy, function and power. A court ruling is a legally binding decision that determines the outcome of a particular ‘controversy’. Conversely, an ethics pronouncement or statement, if not formally adopted into law may be considered a significant professional and moral guide, but is generally not legally enforceable. Having said this, during the creation of laws, policy makers do generally consider medical ethics statements of professional organizations. The moral conscience is a precursor to the development of legal rules for social order and thus, health care providers may greatly influence legal standards by their work in creating professional ethics standards.

Some of the topics discussed in the first tutorial provide examples of ethical/legal overlap, including:

Access to medical care
Informed consent
Confidentiality of health care information and exceptions to confidentiality
Privileged communications with health care providers
Abortion
Physician-assisted suicide

In terms of South Africa’s constitution each person is entitled to human dignity, equality and freedom. This should be the case whether a patient receives medical treatment in the private or public sector. The Government has an obligation to protect the life of every person in South Africa and the patient has the right to receive medical treatment. In terms of section 27 (3) of the Constitution, urgent medical treatment may not be refused in private or public sector. This implies that any patient in need of urgent care should receive medical treatment by the nearest hospital to such an extent that the patient is stabilized.

A patient needs to consent to any examination as the patient has a right to privacy in terms of section 14 of the Constitution. according to the Castell v de Greef 1994 (4) SA 408 (C) decision, a doctor is obliged to warn a patient of relevant and inherent risks of any proposed treatment and or surgery. “A risk is material if, in the circumstances of the particular case, a reasonable person in the patient’s position, if warned of the risk, would be likely to attach significance to it or if the medical practitioner is or should reasonably be aware that the particular patient, if warned of the risk, would be likely to attach significance to it”

Furthermore a patient must consent to medical records being disclosed as this falls within the ambit of section 14 of the constitution. The Patient’s privacy and confidentiality is not legally absolute in terms of ethical requirements. As discussed in the first tutorial, in certain situations the medical professional or health care provider is required to disclose certain information even if it is contrary to the patient’s instructions. It obviously has to be legally justifiable that it was in the patient’s or the general publics’ best interest.

1) In terms of the International Code of Medical Ethics of the World Medical Association, a physician has to preserve absolute confidentiality of all aspects of the patient.
2) The declaration of Helsinki states that in medical research medical doctors should protect human privacy, health, life and dignity.
3) In terms of the South African National Patient’s Charter every patient or client has the following rights: A healthy and safe environment, Participation in decision-making and Access to health care services.

Should a patient be of the opinion that a medical care provider treated him/her in an unethical or unprofessional manner; the Health Professions Council of South Africa should be contacted provided that such a person is registered with HPCSA.

1) A written complaint should be lodged addressed to the Registrar of the HPCSA;
2) The complaint should be signed by the complaint in person;
3) The HPCSA could ask for further detailed information;
4) The relevant practitioner has to forward an explanation and attach any relevant documentation;
5) A committee of Preliminary Inquiry will decide whether a further inquiry should be held, if not the matter will be regarded as finalized;
6) Should a further inquiry be held, further consultations will be conducted and a charge sheet will be forwarded to the practitioner.

Spirituality


Most medical professionals avoid religious or spiritual discussion with patients. Reasons for not opening this subject include the scarcity of time in office visits, fear of imposing upon the patient and lack of familiarity with the subject matter of spirituality. Alternatively, some practitioners incorporate spiritual history into the bio-psycho-social-spiritual interview, and find occasions when sharing their beliefs is beneficial to that patient. Certain issues in modern medicine have major religious and spiritual significance. Some that come to mind are: whether or not to prolong life through artificial means, shortening life through the use of pain medications, or what duty one has to a new born with fatal genetic anomalies. These and numerous others deserve a sensitive dialogue with between health practitioners and patients facing these troubling issues.

Regardless of their own belief system, health professionals should appreciate the possibility that religion and spiritual beliefs play an important role for many of their patients. When illness threatens the health, and especially the life of an individual, the patient will probably come to the professional with both physical symptoms and spiritual issues in mind. For patients facing a terminal illness, religious and spiritual factors often figure into important decision making such as the desirability of CPR and aggressive life-support, or whether and when to fore-go life support.

In a country with the cultural and religious diversity of South Africa, ascertaining a patient’s religious or spiritual beliefs, may be necessary to the successful management of that patient. Religious resources may provide valuable support, both material and psychological to patients. Some patients have described gratitude to their religious community for bringing meals to their family while a parent was at the hospital with a sick child. Others spoke of a visit from a priest, a rabbi, or a minister during their hospitalization as a major source of comfort and reassurance. One patient, self-described as a “non-church-goer,” described his initial surprise at a visit from the hospital chaplain which turned into gratitude as he found in the chaplain a skilled listener with a deep sense of caring to whom he could pour out his feelings about being sick, away from home, separated from his family, frightened by the prospect of invasive diagnostic procedures and the possibility of a painful treatment regimen. Not every medical situation necessitates or warrants questioning into a person’s spirituality. In certain instances it may be construed as invasive or unnecessary. However, in other situations, including terminal cases discussion into spirituality and religion are more pertinent

Whether you are religious, not religious or vehemently anti-religion, your beliefs and portrayal thereof, may affect your relationships with patients. Care must be taken that the nonreligious physician does not underestimate the importance of the patient’s belief system and equally importantly that the religious professional who may have a different belief than the patient, does not impose his or her beliefs onto the patient. In both cases, professionalism and ethical responsibility should supersede the ideology of the health practitioner.

In conclusion, Health professionals can enter a spiritual discussion but they are not obligated to do so. Most importantly, the dialogue should generally be at the invitation of the patient, not imposed by the physician. The purpose of the dialogue should be of benefit to the patient and in no way should the professional put down the patients belief or try to impose their beliefs on them.

Breaking bad news

Breaking bad news is likely one of the more difficult aspects of being a health professional. The fact that it is of such pivotal importance to patients, means that it will likely be well remembered. Most believe that breaking bad news is a born-with skill. This is incorrect. Most health practitioners, who are considered ‘good’ at discussing bad news with their patients report, it is a skill that they have worked hard at. Furthermore, studies in medical education demonstrate that all communication skills can be learned and have long lasting effects.

Oncologist, author and comedian, Robert Buckman, created a six step protocol to breaking bad news. (reproduced directly http://www.surgicalexam.com/interview/Ethics.pdf)

Getting started.
The physical setting ought to be private, with both physician and patient comfortably seated. You should ask the patient who else ought to be present, and let the patient decide–studies show that different patients have widely varying views on what they would want. It is helpful to start with a question like, “How are you feeling right now?” to indicate to the patient that this conversation will be a two-way affair.

Finding out how much the patient knows.
By asking a question such as, “What have you already been told about your illness?” you can begin to understand what the patient has already been told (“I have lung cancer, and I need surgery”), or how much the patient understood about what’s been said (“the doctor said something about a spot on my chest x-ray”), the patients level of technical sophistication (“I’ve got a T2N0 adenocarcinoma”), and the patient’s emotional state (“I’ve been so worried I might have cancer that I haven’t slept for a week”).

Finding out how much the patient wants to know.
It is useful to ask patients what level of detail you should cover. For instance, you can say, “Some patients want me to cover every medical detail, but other patients want only the big picture–what would you prefer now?” This establishes that there is no right answer, and that different patients have different styles. Also this question establishes that a patient may ask for something different during the next conversation.

Sharing the information.
Decide on the agenda before you sit down with the patient, so that you have the relevant information at hand. The topics to consider in planning an agenda are: diagnosis, treatment, prognosis, and support or coping. However, an appropriate agenda will usually focus on one or two topics. For a patient on a medicine service whose biopsy just showed lung cancer, the agenda might be: a) disclose diagnosis of lung cancer; b) discuss the process of workup and formulation of treatment options (“We will have the cancer doctors see you this afternoon to see whether other tests would be helpful to outline your treatment options”). Give the information in small chunks, and be sure to stop between each chunk to ask the patient if he or she understands (“I’m going to stop for a minute to see if you have questions”). Long lectures are overwhelming and confusing. Remember to translate medical terms into English, and don’t try to teach pathophysiology.

Responding to the patients feelings.
If you don’t understand the patient’s reaction, you will leave a lot of unfinished business, and you will miss an opportunity to be a caring physician. Learning to identify and acknowledge a patient’s reaction is something that definitely improves with experience, if you’re attentive, but you can also simply ask (“Could you tell me a bit about what you are feeling?”).

Planning and follow-through.
At this point you need to synthesize the patient’s concerns and the medical issues into a concrete plan that can be carried out in the patient’s system of health care. Outline a step-by-step plan, explain it to the patient, and contract about the next step. Be explicit about your next contact with the patient (“I’ll see you in clinic in 2 weeks”) or the fact that you won’t see the patient (“I’m going to be rotating off service, so you will see Dr. Back in clinic”). Give the patient a phone number or a way to contact the relevant medical caregiver if something arises before the next planned contact.

Despite a good and detailed explanation, difficult situations and emotional distress mean that patients will forget certain facts and often ask the same question to you or different caregivers. Useful ways of dealing with this are getting patients to write down or email questions to which you can reply. Remember this when dealing with patients who have been delivered news by other health professionals. Their lack of the knowledge may well not be the result of poor communication by the health professional. If you do witness marked insensitivity by a health professional, first, examine what happened and if you deem it acceptable discuss it with the health professional. If you see the patient later, you might consider acknowledging it to the patient in a way that doesn’t slander the insensitive caregiver (“I thought you looked upset when we were talking earlier and I just thought I should follow up on that–was something bothering you?”)

Accreditation: PPB004-MD271-0024-2-2013

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Ethics Article 1

No longer accredited for CPD purposes

Ethics, culture and clinical practice

Northeast Florida Medical Supplement, January 2008

Robin N. Fiore, PhD

Excerpt

Issues of cross-cultural communication and diversity of moral beliefs not only impact patient satisfaction, but can also impact clinical outcomes. These considerations require us to work toward “cultural competency,” a topic increasingly included in the training of health professionals and administrators. Cultural competence is defined as “the level of knowledge-based skills required to provide effective clinical care to patients/clients from a particular cultural group.1 However, the ideal of cultural competency has proved to be both overly broad and vague with respect to its practice implications. In order to realize the benefits, specific guidance for practitioners is imperative. How ought we to approach ethical decision making when it involves parties of diverse ethnic and cultural backgrounds? Can it be right to come to different conclusions for different persons in very similar circumstance? What are the dangers of using racial and ethnic generalizations to inform clinical practices? In this article, I discuss best practices of cultural competency that can contribute to issues of specific concern to practitioners; issues that are regularly implicated in clinical ethics consultations: truth-telling, privacy and confidentiality, and patient self-determination, with specific reference to informed consent and end-of-life care

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Accreditation Number: MDB006-MD271-0001-2-2011

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