Transcript Document

Traditional and
Complementary
Medicine
Consumers
driving change
May 2009
Use of Herbal Medicine
Source: WHO Global Atlas of Traditional, Complementary
and Alternative Medicine, 2005.
Widespread Usage
 This is a consumer-led movement:
 Use of traditional medicine (TM) remains widespread in developing
countries: in some Asian and African countries, 80% of the population
depend on traditional medicine for primary health care.
 Use of complementary and alternative medicine (CAM) is
increasing rapidly in developed countries: in many developed
countries, 70% to 80% of the population has used some form of
alternative or complementary medicine.
 More than 100 countries have regulations for herbal medicines.
 Counterfeit, poor quality, or adulterated herbal products in
international markets are serious patient safety threats.
Source: WHO Traditional Medicine Strategy 2002–2005;
WHO Fact sheet on Traditional Medicine
Terminology of TM/CAM
 “Traditional medicine” (TM) is used to refer to systems such as
traditional Chinese medicine, Indian Ayurveda and Arabic Unani Tibb
medicine, and to various forms of indigenous medicine in Africa, Latin
America, South-East Asia and the Western Pacific.
 In countries where the dominant health care system is based on
allopathic medicine, or where TM has not been incorporated into the
national system, it is termed “complementary and alternative”
(CAM). For example in Europe, North America and Australia.
 When referring in a general sense to all of the regions, the
comprehensive TM/CAM is used.
 Allopathic medicine refers to the broad category of medical practice
that is sometimes called Western medicine, biomedicine, scientific
medicine, or modern medicine. [also “urban medicine”]
Source: WHO Traditional Medicine Strategy 2002–2005
World Health Organization Policy
 Framework for action for WHO and its partners, to enable TM/CAM to
play a far greater role. Four objectives:
 Policy: integrate TM/CAM with national health care systems.
 Safety, efficacy and quality: expand knowledgebase on
TM/CAM; provide guidance on regulatory and quality assurance
standards.
 Access: increase availability and affordability of TM/CAM, with an
emphasis on access for poor populations.
 Rational use: promote therapeutically sound use of appropriate
TM/CAM by providers and consumers.
Source: WHO Traditional Medicine Strategy 2002–2005
Beijing Declaration
8 November 2008
 Governments have a responsibility for the health of their people and
should formulate national policies, regulations and standards, as part
of comprehensive national health systems to ensure appropriate, safe
and effective use of traditional medicine.
 Recognizing the progress of many governments to date in integrating
traditional medicine into their national health systems, we call on those
who have not yet done so to take action.
 Governments should establish systems for the qualification,
accreditation or licensing of traditional medicine practitioners.
 The communication between conventional and traditional medicine
providers should be strengthened and appropriate training
programmes be established for health professionals, medical students
and relevant researchers.
Source: WHO Beijing Declaration, 8 November 2008
Including TM/CAM
in the Health System
TM/CAM Legislation and Policy
Source: WHO Global Atlas of Traditional, Complementary
and Alternative Medicine, 2005.
Public Financing for TM/CAM
“any public contribution to any TM/CAM therapy”
South Africa ?
Source: WHO Global Atlas of Traditional, Complementary
and Alternative Medicine, 2005.
The Professional Boards of the
Allied Health Professions Council
ALLIED HEALTH PROFESSIONS COUNCIL
PROFESSIONAL
BOARD 1 FOR:
PROFESSIONAL
BOARD 2 FOR :
PROFESSIONAL
BOARD 3 FOR :
PROFESSIONAL
BOARD 4 FOR :
Therapeutic
Aromatherapy
Ayurveda
Naturopathy
Therapeutic
Massage Therapy
Unani Tibb
Phytotherapy
Therapeutic
Reflexology
Homeopathy
Chiropractic
Osteopathy
3,622 practitioners in May 2007.
Chinese
Medicine and
Acupuncture
International Cover for Homeopathy,
Naturopathy and Phytotherapy
100%
No coverage
Proportion of countries in Region
90%
Public coverage only
56%
70%
79%
60%
50%
Private coverage only
33%
80%
4%
75%
Public and private coverage
74%
74%
100%
44%
40%
30%
1%
44%
20%
16%
16%
10%
25%
19%
11%
5%
0%
Africa
Americas
19%
Mediterranean
Europe
South-East
Asia
Western
Pacific
6%
World
WHO Regions
Available extensively in Europe, the region in which these
therapies were developed. Some public coverage elsewhere but
not in Africa.
Source: Helen Young (2008) The Incorporation of Traditional and Complementary Medicine Benefits in
Healthcare Funding Systems: A Worldwide Review Of Practice. Unpublished UCT project with Prof McLeod.
International Cover for Trad. Chinese
Medicine, Ayurveda and Unani-Tibb
100%
11%
No coverage
90%
Proportion of countries in Region
Private coverage only
37%
80%
Public coverage only
Public and private coverage
70%
68%
79%
60%
72%
11%
92%
50%
100%
89%
40%
41%
30%
3%
20%
21%
5%
21%
10%
16%
8%
11%
Mediterranean
Europe
11%
4%
0%
Africa
Americas
South-East
Asia
Western
Pacific
World
WHO Regions
Acupuncture enjoys the most global popularity. South-East
Asia, the region of origin of Ayurveda and Unani Tibb, offers
extensive public coverage.
Source: Helen Young (2008) The Incorporation of Traditional and Complementary Medicine Benefits in
Healthcare Funding Systems: A Worldwide Review Of Practice. Unpublished UCT project with Prof McLeod.
International Cover for All
South African CAM Modalities
100%
15%
90%
11%
No coverage
Proportion of countries in Region
Private coverage only
80%
Public coverage only
70%
68%
60%
50%
75%
63%
64%
26%
26%
11%
10%
Western
Pacific
World
Public and private coverage
52%
100%
89%
40%
30%
21%
20%
33%
25%
10%
11%
0%
Africa
Americas
Mediterranean
Europe
South-East
Asia
WHO Regions
Public coverage extensive in Europe and South-East Asia.
Globally, public coverage is almost three times more common
than private coverage. In total, over one third of the 130 countries
considered offer some form of coverage for SA-CAM therapies.
Source: Helen Young (2008) The Incorporation of Traditional and Complementary Medicine Benefits in
Healthcare Funding Systems: A Worldwide Review Of Practice. Unpublished UCT project with Prof McLeod.
Denial and The
Power of Exposure
“Fall of the Bamboo Curtain”
 The first definitive study of the use of complementary medicine in the
U.S.A. (Eisenberg et al 1993) estimated that more than one-third of
Americans used alternative therapies.
 Three-quarters of this amount was not reimbursed by insurers or
medical systems.
 The Eisenberg study prompted a fundamental reassessment by
healthcare funders of the direction in which consumers were leading
them. A further study (Eisenberg et al 1998) showed that alternative
medicine visits exceeded visits to primary care physicians.
Source: Caldis, McLeod and Smith (2001) The Fall of the Bamboo Curtain : A Review of
Complementary Medicine in South Africa, South African Actuarial Journal
“Fall of the Bamboo Curtain”
 17 December 1997 was heralded as “The Fall of the Bamboo Curtain”.
It marks the date on which the Journal of the American Medical
Association committed to publishing papers on complementary
therapies as a result of pressure from its readers.
 Internal surveys show ranking of CAM moving from 68 to “the top
three” in the space of one year.
 AMA editors called for papers on CAM, announced a special issue of
JAMA each year on CAM and committed all publications in the group
to carrying more reports on CAM topics.
 John Weeks, editor of the newsletter Alternative Medicine Integration
and Coverage, explained the metaphor of the bamboo curtain as
“being, appropriately, from the era of the Cold War. The freeze in
communication between the medicines, behind which lies were told
(on both sides), is officially melting”.
Source: Caldis, McLeod and Smith (2001) The Fall of the Bamboo Curtain : A Review of
Complementary Medicine in South Africa, South African Actuarial Journal
TM/CAM in US Hospitals
 The 3rd Complementary and Alternative Medicine (CAM) Survey of
Hospitals from the American Hospital Association found that the
percentage of hospitals with at least some CAM services jumped to
37.4% in 2007 from 26.5% in 2005. This is up from 7.7% in 1999, the
first year the AHA included a question on CAM in one of its surveys.
 “Hospitals across the USA are responding to patient demand and
integrating complementary and alternative medicine (CAM) services
with the conventional services they normally provide.”
 Reasons for introducing CAM: 84% of hospitals cited patient demand;
67% cite they found CAM clinically effective; 40% to attract new
patients; 4% insurance coverage.
 “CAM services reflect hospitals' desire to treat the whole person-body,
mind and spirit."
Source: American Hospital Association Health Forum (2008) Complementary and
Alternative Medicine Survey of Hospitals. Summary of Results.
TM/CAM in Teaching Hospitals
 “Teaching hospitals accounted for 38.9% of the respondents with CAM
services.”
 “According to the Association of American Medical Colleges (AAMC).
The percentage of medical schools offering a required course in CAM
has increased from 26% in 2001 to 91% for the graduating class of
2009.
 “CAM is gaining more popularity and interest by the new generation of
physicians hastened by the growing consumer interest.”
Source: American Hospital Association Health Forum (2008) Complementary and
Alternative Medicine Survey of Hospitals. Summary of Results.
TM/CAM in US Managed Care
 “Today more Americans are using complementary and alternative care
to help manage or prevent many health conditions. Many adopt them
as part of their cultural and personal beliefs and to promote a greater
sense of emotional, physical, and spiritual well-being.”
 “The Center for Complementary Medicine is part of Kaiser
Permanente’s integrated delivery system. If you are a member, you
will receive coordinated care from your whole Kaiser Permanente
team. Your complementary medical practitioner, your primary care
physician, and any specialists you are seeing will be able to access
your electronic medical record to learn your health history and
communicate with each other to design a program of care that
meets your unique needs.”
Source: www.kpccm.org/index.html
Board of Healthcare Funders
 2006 Annual Conference :
 Over 70% of audience voted
that TM and CAM was
important to pursue in
medical schemes
African Traditional
Medicine Day and
Decade
 In Africa 80 per cent of people have used traditional medicine at one
time or another in their lives.
 African Traditional Medicine Day is commemorated annually on 31
August to raise awareness and the profile of traditional medicine in the
region, and to promote its integration into national health systems.
 First commemorated 2003, six times since then …
 African Ministers of health in July 2001 declared the period 2001 2010 as the Decade of African Traditional Medicine.
Did you know about this ?
TM/CAM in
South Africa
ANC Health Plan of 1994
“People have the right of access to
traditional practitioners as part of their
cultural heritage and belief system.”
Source: ANC Health Plan 1994; South African Health Review 2007,
Chapter 12.
Regulation of Practitioners
Department of
Health
Health Professions
Council
Dental Technicians
Council
Nursing Council
Pharmacy Council
Allied Health
Professions
Council
Traditional Healers
Council
Healthcare Practitioners in SA






Some 34,000 doctors (including some 7,000 GPs in private practice);
11,000 pharmacists;
100,000 professional nurses;
84,000 staff nurses and auxiliaries;
3,600 complementary medicine practitioners; and
185,500 traditional medicine practitioners.
Why are all these TM and CAM practitioners
not covered by medical schemes ?
Source: SAHR 2006; SAHR 2007, Chapter 12.
Complementary Medicine Trade
 Health Product Association formed 1978 as association of
manufacturers, importers and distributors of complementary medicines
and health products.
 1996 survey: combined turnover of members was R0.881 billion.
 2003 survey: 53% increase to sales revenue of R1.348 billion.
 In 2003, the market at consumer level was some R1.9 billion. This
is 22% of the medicine expenditure by medical schemes of R8.6 bn.
But seldom reimbursed by medical schemes at present.
 Amount spent on CAM medicines is considerably higher than spent on
CAM practitioners. In line with worldwide trends to self-medication
using complementary medicine.
Source: South African Health Review 2007, Chapter 12.
HPA Turnover relative to
Medical Scheme Medicines
Medicine spend by Medical Schemes
10,000,000,000
HPA Member Turnover
9,000,000,000
Consumer level
8,000,000,000
Rands
7,000,000,000
6,000,000,000
HPA spend usually
out-of-pocket by
consumers
5,000,000,000
4,000,000,000
3,000,000,000
2,000,000,000
1,000,000,000
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
0
Year
HPA products at consumer level were 22% of medical scheme spend
on medicines outside hospital in 2003. In 2007, HPA turnover
estimated to be 43% of medical scheme spend on medicines.
Source: South African Health Review 2007, Chapter 12; Council for Medical Schemes
Annual Reports; latest HPA Survey.
Traditional Medicine Trade
 TM trade in South Africa is a large and growing industry. There are
some 27 million consumers of traditional medicine. Trade of these
medicines contributes some R2.9 billion to the economy (2006).
 The amount spent represents 5.6% of the National Health budget, or
equal to the whole Mpumalanga Health budget, or equal to the KZN
Provincial Hospital budget.
 72% of the Black African population in SA estimated to use TM. Use
not confined to poor, rural and uneducated users.
 The average frequency of TM use per consumer is 4.8 times per year.
 The use of TM is a positive choice made by consumers, who are
often prepared to pay a premium price for these products and
services, even when this exceeds the cost of western treatments.
 At least 133,000 income earning opportunities, including 63,000
plant harvesters, 3,000 street traders and 68,000 full-time herbalists.
Source: South African Health Review 2007, Chapter 13.
Formal Sector TM Trade
Source: South African Health Review 2007, Chapter 13.
TM/CAM in Medical
Schemes
Generic Medical Scheme
Benefit Structure
Day-to-day benefits:
Major Medical:
in-hospital and
chronic medicine
Above threshold
benefit
primary care
practitioners and
acute medicine
Above
PMBs
Self-funding gap
Prescribed Minimum
Benefits (PMBs)
TM/CAM paid
out-of-pocket,
if at all.
Medical Savings
Account
Pooled benefits – annual
routine benefits
Paid from risk pool with no limits or co-payments
Paid from risk pool with limits, co-payments, deductibles
Self-funded
Other
7.5%
Total Private Hospitals
22.9%
1990
Medical Scheme
Benefits
GPs, Primary Care and
Dental
25.0%
Specialists, Allied and
Support
16.0%
Total Public Hospitals
5.5%
Medicines out of
Hospital
23.2%
GPs, Primary Care and
Dental
15.4%
Other
2.5%
Total Private Hospitals
34.5%
2006
Hospital and specialist
expenditure has escalated faster
than other areas.
Massive shift to covering
hospital and specialist visits and
away from primary care.
Primary care covered more from
out-of-pocket money.
Medicines out of
Hospital
16.9%
Total Public Hospitals
0.5%
Specialists, Allied and
Support
30.1%
Source: Registrar’s Annual Reports
Medical Scheme Spend on CAM
80,000,000
Other CAM Therapies
70,000,000
Homeopaths
Chiropractors & Osteopaths
Nominal Benefits
60,000,000
50,000,000
40,000,000
30,000,000
20,000,000
10,000,000
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
0
Year
Definitions have altered for “Other” over the years. 2000 to 2003
data looks odd. Steady growth – BUT total CAM spend was 1.7% of
that on GPs in 2007. Not always captured as CAM ...
Mostly not covered: people paying out-of-pocket.
Source: Council for Medical Schemes Annual Reports
Private Insurers in Australia
Osteopathy/ chiropractic
50.0%
50.0%
Homeopathy
86.8%
SA-CAM Modalities
Naturopathy
100.0%
Phytotherapy
71.1%
Aromatherapy
28.9%
47.4%
52.6%
Massage
100.0%
Reflexology
18.4%
81.6%
Chinese medicine /
acupuncture
97.4%
0%
covered
13.2%
not covered
10%
20%
30%
40%
50%
2.6%
60%
70%
80%
90%
100%
Proportion of private insurers covering therapy
The Journal of the Australian Traditional-Medicine Society gives a
summary of coverage of TM/CAM therapies by Australian private
health insurers as at March 2008. Covers all 38 registered insurers.
Source: Helen Young (2008) The Incorporation of Traditional and Complementary Medicine Benefits in
Healthcare Funding Systems: A Worldwide Review Of Practice. Unpublished UCT project with Prof McLeod.
Government Employees
Medical Scheme
 Major positive development is return
by Government to a restricted
scheme for public sector workers.
 Very rapid growth from January 2006.
 By end 2007, was already the third
largest medical scheme in South
Africa and the largest restricted
(employer or union-based) scheme.
 Late 2008: GEMS now has 300 000 principal members and provides
healthcare cover to over 800 000 people. "What is more, 54% of
GEMS' members previously did not access the employer subsidy for
medical schemes. This means that in excess of 430 000 people who
did not previously have healthcare cover now do."
Source: GEMS web-site: www.gems.gov.za
 Major positive development is return
by Government to a restricted
scheme for public sector workers.
Covers 10 CAM modalities
and Traditional healers
Source: GEMS web-site: www.gems.gov.za
TM/CAM in the
future National
Health Insurance
system?
Public-Private Coverage
South Africa 2005
47.0m people
Private Health
Insurance
14.9%
7.0m people in voluntary
Medical Schemes using
private primary care and
private hospitals
R9,500 per person pa
Some Private +
Public
20.9%
Public Sector
64.3%
30.2m people using public
clinics and hospitals
R1,300 per person pa
9.8m people using
private primary care
out-of-pocket and
public hospitals
R1,500 per person pa
Source: McIntyre D., van den Heever A. Social or National Health Insurance.
In: Harrison S., Bhana R., Ntuli A., editors. South African Health Review 2007.
Durban: Health Systems Trust; 2007. URL: http://www.hst.org.za/publications/711
Current Healthcare Financing
Medical Schemes
Provision /
Delivery
Out-ofpocket
Social Insurance (RAF, COIDA)
Provincial Health
Departments
Other
governmental
Purchasing
National Treasury
allocation to Provinces
Tax relief
No pooling
(individual
purchasing)
Pooling
General taxation (SARS)
Bargaining Council Funds
Revenue
collection
Private providers
NHI debate is a debate about the future role of medical schemes
Kutzin Framework diagram drawn using value of expenditure
Two Paths to Universal Coverage
Through SHI to NHI
 Policy from 1994 to 2007
 Gradual, begin with highest paid
workers and their families. Need
subsidies for workers earning
below tax threshold.
 Medical Schemes are vehicles
for NHI, buy from private and
(increasingly) public providers.
 Competitive schemes, with Risk
Equalisation Fund.
Direct to NHI
 “Post-Polokwane” Dec 2007
 ANC election promise: immediate
“within 5 years”
 Tax and progressive social
security contribution.
 One central fund, with public and
private providers.
 Role for medical schemes
undefined – perhaps top-up only?
 Package “free” but not defined.
Not yet in
public domain
ANC Manifesto on NHI




“The ANC is determined to end the huge inequalities that
exist in the public and private sectors by making sure that these
sectors work together.”
Introduction of the National Health Insurance System (NHI) system,
which will be phased in over the next five years. The principles of NHI
will include the following:
NHI will be publicly funded and publicly administered and will provide
the right of every South African with access to quality health care,
which will be free at the point of delivery. People will have a choice of
which service provider to use within a district.
The social solidarity principle will be applied and those who are
eligible to contribute will be required to do so, according to their ability
to pay, but access to health care will not be according to payment.
Participation of private doctors working in other health facilities,
in group practices and hospitals, will be encouraged to participate
in the NHI system.
Source: African National Congress 2009 Manifesto Policy Framework
TM/CAM and Universal Coverage
Through SHI to NHI
Direct to NHI
 Medical scheme minimum
 One central buyer. Nothing said
benefits exclude TM/CAM in
about including TM or CAM
definitions for chronic disease
healthcare providers.
treatment.
 Package of cover not yet defined.
 A patient using TM/CAM not seen
as a “treated patient” for the Risk
Not yet in
Equalisation Fund. Schemes
public domain
would not be reimbursed for a
chronic person using this
treatment.
 Medical schemes cover TM/CAM
through savings accounts, if at all.
TM/CAM Integration in South Africa
 Health legislation which includes TM/CAM
 Draft National Policy on African Traditional Medicine – July 2008
 Technical barriers to exclusion largely removed:
 Registration and licensing of practitioners.
 [Allied Health Professions Council of SA]
 [Interim Traditional Health Practitioners Council of SA]
 Practice code numbers [Board of Healthcare Funders under
mandate from Council for Medical Schemes].
 Inclusion in National Health Reference Price List [national DoH].
 NAPPI coding of all medicines [industry bodies].
 ICD-10 coding by practitioners for billing medical schemes
Source: South African Health Review 2007, Chapter 12.
Consumer Action on TM/CAM
 Help break the silence on TM and CAM usage.
 Medical schemes are owned by their members and managed by
boards of trustees: 50% elected by members.
 Need medical schemes members to ask at AGMs why TM and CAM
benefits have not been included.
 Press briefings by medical schemes: ask about TM and CAM usage
and why benefits have not been included.
 Definition of Prescribed Minimum Benefits and Risk Equalisation Fund
(Council for Medical Scheme briefings): keep asking about TM and
CAM and why they are excluded.
 National Health Insurance: ask why proposals for NHI are not in the
public domain. Where is the TM and CAM cover in the proposal ?
People’s Charter
for Health
 The People's Charter for Health is a statement of shared vision, goals,
principles and calls for action. It is the most widely endorsed consensus
document on health since the Alma Ata Declaration of 1978.
 People’s Charter calls for the provision of universal and comprehensive
primary health care, irrespective of people’s ability to pay.
 Calls on people of the world to:
 Support, recognise and promote traditional and holistic healing systems
and practitioners and their integration into Primary Health Care.
Source: People’s Charter for Health, adopted in Dhaka, Bangladesh, December 2000
National Health Insurance
Want a National Health Insurance system that
integrates medical schemes
With a benefit package based on primary care
That fully integrates Traditional Medicine and
Complementary Medicine
To enable consumers to choose according to
their cultural heritage and belief systems.
Dr Alan Tomlinson
[email protected]
http://www.hpasa.co.za/
Professor Heather McLeod
[email protected]
www.hmcleod.moonfruit.com