7 June 2002: TAC Statement on Medical Schemes Research Conducted by TAC and CARE

96% of rape survivors and 92% of pregnant mothers can get access to ARVs on medical schemes
Opportunistic infections are also effectively covered
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The Treatment Action Campaign (TAC) welcomes the results of research done on HIV Benefits in Medical Schemes in 2002 by the Centre for Actuarial Research at the University of Cape Town in association with our organisation. A monograph will be released later in the month. By Tuesday, a slideshow on this research will be available for download from the TAC website, www.tac.org.za. One of the most important pieces of legislation promulgated by South Africa's first democratic government is the Medical Schemes Act (Act 131 of 1998). Unfair discrimination against people on a range of grounds including "any medical condition" is prohibited by private medical schemes. The AIDS Law Project, AIDS Consortium and current TAC members supported the passage of the legislation against powerful forces including the insurance industry, the Chamber of Mines and others. This survey shows conclusively that the Medical Schemes Act has been successful in ensuring coverage by medical schemes of people with HIV/AIDS.

Methodology and Survey Coverage

A detailed questionnaire was sent to the principal officers of all medical schemes registered in South Africa. More than 50% of schemes responded to the survey - these were predominantly large schemes. The survey covers 5, 290, 030 beneficiaries or 80% of people who have access to a medical aid including 75% of open schemes beneficiaries and 94% of restricted scheme beneficiaries. Small restricted schemes are under-represented and there is poor coverage of medium and small open schemes. In these schemes, we assume that coverage and access to benefits remain limited. TAC hopes to undertake work with these schemes to ensure adequate coverage.

Results

4% of beneficiaries only have access to prescribed minimum benefits (PMBs) for HIV/ AIDS. Current PMBs only cover treatment of opportunistic infections. 89% of beneficiaries are covered by a disease management programme. Aid for AIDS accounts for 36% of beneficiary coverage.

Education, Counselling and Testing

The survey shows extensive coverage of counselling, testing and education. This can be improved but it demonstrates that there has been a pro-active policy position that has ensured coverage.

Opportunistic infections

Selected opportunistic infection coverage by beneficiary shows that more than 84% of beneficiaries have access to key interventions for opportunistic infections. TAC believes this shows that we can reach 100% PMB coverage over the next year. 20 different options offered by medical schemes are in breach of their legal obligations - they finance PMBs through membership savings. This is unlawful.

MTCT

92% of beneficiaries on private medical schemes have access to antiretroviral therapy to reduce mother-to-child HIV transmission. The choice of drugs varied between AZT only, AZT and lamivudine, or nevirapine. 84% also had access to a caesarean section. Only 47% of schemes offered formula feed and only 77% offered MTCT specific counselling.

PEP for sexual assault and occupational injury

96% beneficiaries have access to ART in the event of sexual assault. 94% of beneficiaries have access to PEP for occupational injury. This is highly commendable.

Antiretroviral therapy coverage and access

8% of beneficiaries are not covered for any ARV treatment. 21% of beneficiaries can opt to use mono-therapy - that is, one drug only while 73% of beneficiaries can still access dual therapy. 90% of beneficiaries can access triple-therapy. Medical schemes have introduced surveillance of drug efficacy (85%) and treatment counselling (88%).

TAC welcomes the increased coverage by medical schemes that include ARVs for treatment of HIV/AIDS. However, we are seriously disturbed by the continued use of mono- and dual-therapy. This will lead to early drug resistance foreclosing the treatment options of people with HIV/AIDS and allowing drug resistant HIV to circulate in the population. Medical schemes have the unique opportunity to follow international standards and to limit any damage because of the current low-uptake through the schemes.

Access

Fewer than 0.3% of beneficiaries surveyed access their benefits. This is a disturbing result which might be explained by one or more of the following causes:

a. inadequate information being made available to beneficiaries,
b. continued HIV stigma and discrimination,
c. public confusion over the safety and efficacy of anti-retroviral drugs,
d. the contributions members have to make to receive these benefits are, possibly, too high, and
e. the inequitable distribution between the private and public health care sectors of people with HIV.

These are obstacles that can be overcome. TAC will work with medical schemes to encourage beneficiaries to access HIV/AIDS benefits. We will also make specific recommendations to the Council for Medical Schemes. We hope to undertake further research to investigate the pricing of benefits.

This report is timely and a necessary part of the Treatment Congress that will be hosted by Cosatu and TAC at the end of this month. We call on government to ensure that a comprehensive treatment plan including antiretroviral coverage in the public sector becomes a reality to ensure that we save the lives of more than 4.7 million people with HIV/AIDS in South Africa.

TAC wishes to thank Professor Heather McLeod and Andrew Stein of the Centre for Actuarial Research for their commitment and work.