Diagrama de Instalación

Medical care for education sector employees has new importance due to the increased burden of disease created by HIV/AIDS.

• Basic health care can have a large impact on well-being, morale and performance of employees with HIV/AIDS.36

• Access to ARV treatment, which may be possible on a large scale under medical aid entitlements, will have a major impact on ability to manage impacts on individuals and loss of staff and skills.

• Health care for HIV/AIDS has large potential cost implications.

The following sections focus on the private sector medical aid cover provided by the Public Service Employees Medical Aid Scheme (PSEMAS). However, systematic coordination between education and public sector health services is likely to be increasingly important. Effective management of illness among staff not on medical aid is needed, and public sector services are relied on by medical aid members in areas where there is limited private sector capacity.37

All public servants are entitled to join PSEMAS.38 Although no statistics were available of the proportion of education sector employees on medical aid, participation is high. In 2001 there were around 120 000 members and dependents covered by the scheme. Cost barriers to joining the medical aid are low: principal members contribute $60 per month and $30 per month for each dependent. Government funds 95% of contributions out of general government revenue. Members are required to make co-payments of only 5% of the cost of consultations.

Benefits to PSEMAS members are generous and cover a wide range of HIV/AIDS-related care. There are no financial limits on claims or medications, and only a small number of services, specified in Public Service Staff Rules, that are excluded from cover. There are no exclusions or limits specific to HIV/AIDS. The scheme also pays for transport in cases that are referred to major centres.

Overall, under current conditions, there are relatively few barriers to education staff with HIV/AIDS accessing PSEMAS benefits, even if they only join once they realize that they have HIV/AIDS.

Key challenges

Among important pre-existing challenges to the role of PSEMAS are the following:

36

Basic interventions include primary health care for early and effective treatment of TB and other opportunistic infections, certain basic prevention treatments and psychological or nutritional support.

37

Outside of Windhoek, most hospital care and other key services are provided by public sector hospitals and services such as Namibia Institute of Pathology.

38

Chapter 3: How will HIV/AIDS affect capacity to deliver education 47

• Cost escalation. Over the last three years, costs have persistently risen above expected levels and

there are concerns about sustainability. This was a major reason for a review of medical aid strategy since April 2001. One cost driver has been rapidly increasing membership.39 Overall, however, the scheme reports cost escalation that is lower than experienced in medical aid systems in South Africa. To a significant extent this seems to be due to limited access to private medical care. Claims by members in more remote areas tend to be lower than for urban counterparts.

• Active management of costs, effectiveness and fraud. This is hampered by several factors.

• Legal and regulatory restrictions on ability to manage care and costs or “interfere” in treatment decisions by patients and providers. In terms of the Act and Public Service Staff

Rules the scheme has no effective power to intervene in treatment decisions by members or doctors, even if these are grossly wasteful.40 Some initiatives such as generic drug substitution are being promoted, but there is no active pharmaceutical benefit management programme or other managed care.

• Difficulties in preventing membership card “sharing” with non-members, a practice which is

thought to be widespread.

• Limited incentives and requirements for the scheme administrators to invest in systems to enhance monitoring and management of care. Apart from legislative constraints, current

contracts with administrators are of quite short duration, so extensive investment in developing new systems is risky for the administrators, who may not benefit from the investment.

• Feasibility of service delivery particularly in rural areas, especially for more sophisticated

services, is a problem due to limited private (and public) sector capacity.

HIV/AIDS impacts and implications

AIDS adds complexity to challenges already faced by the scheme and its members. Potential for the HIV/AIDS epidemic to increase costs is substantial. HIV/AIDS is also a complex disease with rapidly changing treatments. Many doctors often do not keep up with best practice developments, and the effectiveness and cost effectiveness of their treatment cannot be assumed without active guidance and support. In addition, ARV treatment and other aspects of HIV/AIDS management often require quite sophisticated laboratory and other diagnostic services.

The medical scheme is already identifying important trends that are, or are thought to be, HIV/AIDS related. These include:

• Increasing membership , with indications that some of this is due to new people joining the

scheme when they realize that they or dependents have HIV/AIDS.

• Increasing costs and use of HIV/AIDS related services. The scheme estimated that in 2000 15% of

costs of chronic medication were HIV related and that HIV/AIDS related costs had increased by 20-30% over the year.41 Antiretroviral use had been noted to be highest in north eastern regions.

• Large numbers of claims for HIV-infected infants, often associated with “high cost families” where more than one member has large health care needs.

Medical aid costs are likely to be the single largest HIV/AIDS related cost. However, ARVs seem to be a potentially affordable component of HIV/AIDS strategy for the education system. Projections of ARV costs are subject to many assumptions, particularly around drug prices. They suggest however, that by 2010, an efficient programme could add the equivalent of NS$ 28 million to the annual cost of

39

The number of beneficiaries increased from 110 000 to 120 000 between 2000 and 2001.

40

A recent initiative was to identify and track high claiming beneficiaries but the scheme had no power to intervene to manage their care and costs.

41

The scheme attempts to identify HIV/AIDS related utilisation through tracking certain medication and services that tend to be characteristic of HIV/AIDS treatment. This may well not pick up all cases.

Chapter 3: How will HIV/AIDS affect capacity to deliver education 48 employment for teachers, equivalent to around 2% of expenditure on primary and secondary education (Table 3.4).42 Cumulative costs between 2002 and 2010 would be of the order of N$146 million.

Table 3.4. Potential costs of ARV therapy for educators No of employees on

ARVs

Total costs* ARV treatment as a % of total MBESC basic salaries

2001 400 $5.6 million 0.25

2005 1400 $12.9 million 0.9

2010 3020 $28 million 1.9

* N$ at constant 2001 prices. Note actual 2001 prices would be higher due to current drug prices and cover of dependents. PSEMAS data suggested expenditure of N$ 15 million on chronic AIDS medication in 2000.

Recommendations – medical care

Successful and affordable medical cover, particularly for ARVs, is likely to be a critical component of education sector HIV/AIDS strategy. A lead role by the education Ministries in promoting effective strategy seems appropriate. They are the largest employing sector and their employees are relatively skilled and affluent, with good prospects of successful therapy. Widespread ARV access may be a critical part of strategy to sustain the skills base for education delivery (see discussion of skills impacts in a subsequent section). However, the education sector and other sectoral partners have not so far given systematic attention to this issue. The following recommendations should be considered.

• Develop a strategy on medical aid with MOHSS, Finance, OPM and other Ministries. Particular

issues to be addressed include:

• The legislative and regulatory framework, to reduce constraints on ability to manage care and

costs.

• Implementing disease management programmes for people with high claims. This may

include not only people with HIV/AIDS, but also other chronic, high cost conditions and high cost acute conditions.

• Options for cost sharing, including increasing member contributions and possibly co- payments on certain services to assist in covering extra costs of HIV/AIDS. Particularly for

higher income members, contribution rates are very low and increased contributions may be possible.

• Options for bulk purchasing of ARVs to ensure that they are affordable.

• Strategy to increase access to effective care particularly in remoter areas.

• Potential need to fast track effective ARV care strategy for key cadres of skilled human resources in Namibia , such as educators.

• Set up routine reporting systems with PSEMAS to provide statistical information on the numbers of education employees within various categories that are on HIV/AIDS and ARV treatments.43

• Work with PSEMAS to increase education employees and managers awareness of the importance and potential of HIV/AIDS care. Stress the importance of early diagnosis of HIV status, treatment

compliance and ARV therapy.

42

This assumes a cost of N$ 9200 for ARVs and monitoring per patient per annum and 85% uptake. This level of pricing seems achievable as it has been negotiated by countries such as Botswana. However, current private sector prices of ARV drugs in Namibia remain higher than this at around $ 19 200 although they have fallen substantially from $45 600 per annum. Note also that costs continue to rise after 2010 in the absence of behaviour change, lower prices or new technology.

43

At present, PSEMAS systems do not allow for routine identification of members employing Ministry or their job categories, or categorisation by age and gender, but this should be relatively simple to rectify.

Chapter 3: How will HIV/AIDS affect capacity to deliver education 49

• Encourage direct liaison with health care providers by education managers at Region and lower levels to ensure that systems enable effective access of staff to HIV/AIDS care and to facilitate

workplace management of illness and absenteeism. Due respect of confidentiality in specific cases should clearly be observed.

• Create workplace environments and policies that facilitate effective compliance particularly for staff on ARV and TB treatment. Consider issues such as supervised directly observed daily

treatment of staff for TB and ARVs in workplaces where appropriate.