Submission on Draft Regulations to the Medical Schemes Act 131 of 1998

Section 27(2) of the Constitution imposes on the state a positive obligation to take reasonable measures to realise the right of access to health care services for all. By enacting the Medical Schemes Act, 131 of 1998 (the Act), government has created a powerful framework for the effective regulation of the private medical scheme industry.

By increasing access to private health care for thousands of people who were previously excluded from membership by virtue of the race, gender, age and health status, the Act makes a substantial contribution towards discharging this positive obligation. The TAC and the ALP recognise that the DoH has played a crucial role in paving the way for persons living with HIV/AIDS to join a medical scheme and thereby avoid being subjected to unfair discrimination.

The ALP supported the enactment of the Medical Schemes Bill (now the Act) on the grounds that it gave effect to section 27(1) and (2) of the Constitution. The ALP’s oral and written submissions on the Bill dealt with the issue of private and public benefits in detail. TAC and the ALP remain committed to the principles of the Act: non-discrimination, increased access to health care services, prescribed minimum benefits (PMBs) and effective regulation of the privatemedical industry.

The Act guarantees beneficiaries access to a minimum standard of care through the promulgation of regulations and a list of PMBs. TAC and the ALP support the adoption and implementation of PMBs for all health conditions on the understanding that PMBs guarantee beneficiaries the right of access standard essential health care services for all health conditions.

In our view the availability of ARV treatment for users in the public health sector means that private sector patients must also have access to the same or higher standard of benefits that include access to ARV treatment.

The “Explanatory Note” to the current set of PMBs recognise that frequent changes in medical practice and technologies warrant periodic changes. It unambiguously states that one of the objectives of introducing PMBs is ‘to encourage improved efficiency in the allocation of Private and Public health care resources’. Calling for a review of the PMBs every two years, the Note makes it plain that such periodic reviews must ‘focus specifically on the development of protocols for the medical management of HIV/AIDS’, and that ‘recommendations for the revision’ will be on the basis, inter alia, of ‘cost effectiveness of health technologies or interventions’ and ‘consistency with developments in health policy’.

Significantly, the mandatory provision of ARV treatment in the private sector will in our view reduce the burden on the public sector ARV treatment programme. This is because without adequate private sector ARV treatment (mainly through medical schemes) patients will continue to be dumped on the public sector.

Regulations to the Medical Schemes Act – 2004 – TAC ALP.pdf